Abstracts and Congress Topics

Transcription

SGC Journal SSC
Abstracts and Congress Topics
95. Jahreskongress der Schweizerischen Gesellschaft für Chirurgie
6. Gemeinsamer Jahreskongress mit der Schweizerischen
Gesellschaft für Thorax-, Herz- und Gefässchirurgie
Basel, 28.-30. Mai 2008
95e congrès annuel de la Société Suisse de Chirurgie
6e congrès annuel en commun avec la Société Suisse de
Chirurgie Thoracique et Cardio-Vasculaire
swiss knife 2008; special edition
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Supplementum 1/05, Schweiz.
Arzneimittelkompendium, www.documed.ch
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Editorial
Der Jahreskongress der
Chirurgischen Fachgesellschaften:
Partnerschaft für Innovation, Weiterbildung und Qualität der Chirurgie
Le congrès annuel des sociétés spécialisées en chirurgie: Un partenariat
pour l‘innovation, la formation postgraduée et la qualité de la chirurgie
Liebe Leserinnen, liebe Leser
Chères lectrices, chers lecteurs
Die Kongressausgabe von swiss knife liefert Ihnen neben den Abstracts und
den Kongressbeiträgen erneut einen Querschnitt aktueller chirurgischer Themen aus den verschiedenen Regionen des Landes.
L’édition de swiss knife consacrée au congrès vous apporte une fois de plus,
à côté des abstracts et des contributions au congrès, un aperçu des différents
thèmes d’actualité de la chirurgie dans les différentes régions du pays.
Mit dieser Leistungsshow der schweizerischen Chirurgie möchten wir Sie
zum Besuch der wissenschaftlichen und berufspolitischen Sitzungen, den
Diskussionsforen spezieller Chirurgengruppen und der Industrieausstellung
animieren. Wir danken allen, die zum Kongress beitragen und wünschen einen fruchtbaren Gedanken- und Erfahrungsaustausch.
Nous espérons que cette présentation du savoir-faire de la chirurgie suisse
vous incitera à assister aux sessions scientifiques et de politique professionnelle, à participer aux forums de discussion de groupes de chirurgiens spécialisés et à visiter l’exposition industrielle. Nous remercions toutes celles et
tous ceux qui contribuent au bon déroulement de notre congrès qui, nous
l‘espérons, sera le théâtre de fructueux échanges d’idées et d’expériences.
Chirurgen sind eine Familie. Die Gemeinsamkeit der chirurgischen Spezialitäten ist heute wichtiger denn je, denn nur gemeinsam können wir Leistungsfähigkeit und Attraktivität der Chirurgie erhalten und weiterentwickeln.
Deshalb möchten wir Sie besonders auf die gemeinsamen Sitzungen dieses
Kongresses aufmerksam machen und Sie dazu einladen:
• Die Live-Übertragung typischer Operationen, erstmals in High-definitionQualität per Satellit, ist nicht nur eine technische Premiere: Sie erlaubt die
Verfolgung und die Diskussion der Verfahren in real time unter expliziter
Berücksichtigung ethischer Standards (Kongress-Programmheft p. 69).
• Eine Hauptsitzung fokussiert bewusst auf die Chancen der DRG. Damit soll
auf Notwendigkeit und Möglichkeiten der konstruktiven Beeinflussung einer Vergütungsform hingewiesen werden, welche die Anreizmechanismen
und Organisation der Medizin fundamental umstellen wird.
• Eine zweite gemeinsame Hauptsitzung wird den Stellenwert von Stammzellen in der Chirurgie darstellen. Diese Zukunft hat nämlich bereits begonnen: Erste chirurgische Stammzelltherapien haben mit der Übernahme der
Behandlungskosten durch die Krankenkassen im nördlichen Nachbarland
Eingang in das chirurgische Behandlungsreservoir gefunden.
Die Schweizerische Gesellschaft für Chirurgie und die swiss knife Redaktion
heissen Sie zu einem viel versprechenden und stimulierenden Kongress in
Basel willkommen!
Les chirurgiens forment une famille. Resserrer les rangs de la communauté
des chirurgiens de toutes disciplines est aujourd’hui plus important que jamais
car ce n’est qu’ensemble que nous pourrons préserver et améliorer l’efficacité
de la chirurgie et l‘intérêt pour ce métier. C’est pourquoi nous souhaitons
plus particulièrement attirer votre attention sur les sessions communes de ce
congrès et vous inviter à y prendre part:
• La retransmission en direct d’opérations caractéristiques, qui, pour la première fois, s’effectuera par satellite en qualité haute définition, ne constituera pas seulement une première technique: elle permettra de suivre et de
commenter les techniques en real time en tenant explicitement compte de
standards éthiques (Cahier de programme de congrès p. 69). • Une session principale sera délibérément consacrée aux chances offertes
par les DRG. Il devrait ainsi être possible d’attirer l’attention sur la nécessité
et les possibilités, pour une forme de rémunération qui va modifier radicalement les mécanismes de stimulation et l’organisation de la médecine,
d’exercer une influence constructive.
• Une deuxième session principale commune traitera de l‘importance des
cellules souches en chirurgie. En effet, dans ce domaine, l’avenir a déjà
commencé: avec la prise en charge des frais de traitement par les caisses
d’assurance maladie, les premières thérapies chirurgicales à base de cellules souches ont fait leur entrée dans la panoplie des traitements chirurgicaux chez nos voisins du nord.
La Société Suisse de Chirurgie et la rédaction de swiss knife vous souhaitent
la bienvenue à Bâle pour un congrès prometteur et stimulant!
Michael Heberer SGC-Präsident
Markus Zuber
Für die swiss knife Redaktion
P.S. Die swiss knife special edition 2008 wurde von Dr. med. Paolo
Abitabile und Prof. Dr. med. Christoph Maurer mitgestaltet.
Abstracts Br J Surg 2008: pdf auf www.chirurgiekongress.ch
Der nächste Kongress der SGC-Gruppe findet in Montreux vom
10.-12. Juni 2009 statt.
Die Abstract Deadline ist der 14. Januar 2009.
Michael Heberer
Président de la SSC
Markus Zuber
Pour la rédaction de swiss knife
P.S.Paolo Abitabile, docteur en médecine, et le professeur Christoph Maurer,
docteur en médecine, ont participé à la réalisation de la présente édition
spéciale de swiss knife.
Abstracts Br J Surg 2008: pdf sur www.chirurgiekongress.ch
La date limite de réception des abstracts est fixée au 14 janvier 2009.
Le prochain congrès du groupe SSC aura lieu à Montreux du 10 au 12 juin
2009.
swiss knife 2008; special edition Surgical Instruments
Surgical Instruments
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Sensible developments for us mean instruments that function in such a way that
they decisively and positively influence the course of a surgical operation, whilst not
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Arnold Bott AG · bott@polymed.ch
Mediwar AG · info@mediwar.ch
Content
Michael Heberer, Markus Zuber3
Der Jahreskongress der Chirurgischen Fachgesellschaften: Partnerschaft für
Innovation, Weiterbildung und Qualität der Chirurgie
Le congrès annuel des sociétés spécialisées en chirurgie: Un partenariat pour
l‘innovation, la formation post-graduée et la qualité de la chirurgie
Ossi Robertson
Die neuste Videoinstallation «Origin of Life» 2008
7
Giulio Spagnoli, Ivan Martin, Andrea Banfi, Michael Heberer
Surgical Research: Shaping Tomorrow’s Therapies
8
Norbert Suhm, Augustinus L. Jacob, Marcel Jakob
Das Management von Polytraumapatienten: ATLS oder mehr?
9
Mauro Arigoni, Raffaele Rosso
Diagnostique et thérapie du traumatisme abdominal
23
Visceral Surgery
44
25
Visceral Surgery
45
26
Research
46
31
Video
47
34
Cardiac Surgery
49
35
Visceral Surgery
50
43
Research
52
44
Vascular Surgery
54
51
Vascular Surgery
55
52
Visceral Surgery
56
53
General and Trauma Surgery
58
54
60
55
Visceral Surgery
61
58
Cardiac Surgery
65
P
Posters (Fortsetzung)
67
11
Corinne J. Geppert, Nikolaus L. Renner
13
Die Behandlung der Klavikulaschaftfrakturen – Chirurgie wann und wie?
Anja Grosskreutz, Dominik Heim
Osteosynthese bei Osteoporose: Immer LCP?
15
Abstracts
Session Topic
17
03 Visceral Surgery
17
04 General and Trauma Surgery
18
20
06 Visceral Surgery
22
07 Research
24
27
10
Thoracic Surgery
29
11
Visceral Surgery
30
13
Vascular Surgery
32
15
Thoracic Surgery
33
16
Vascular Surgery
35
17
38
19 Research
41
21
Video
43
Mark A. Rudin, Kurt P. Käch
81
Die palmare winkelstabile Plattenosteosynthese der instabilen distalen Radius
fraktur: Modetrend oder Methode der Wahl?
Christian Marazzi, Jörg Peltzer
83
Minimal invasive Plattenosteosynthese zur Behandlung der lateralen Malleolar
fraktur, eine biologisch günstige Alternative zum herkömmlichen offenen
Standardverfahren
Florian Dick, Jürg Schmidli
Die elektive Versorgung des infrarenalen Aortenaneurysmas
85
Hervé Probst, Nicolas Demartines
Laparoscopie abdominale: possibilités et limites
86
Valentin Neuhaus, Matthias Turina, Othmar Schöb
89
Stellenwert der Laparoskopie beim adhäsionsbedingten Dünndarmileus
Axel Andres, Michel Erne
Y a-t-il encore une place pour la chirurgie anti-reflux en 2008?
90
Selim Dinçler, Peter Buchmann
Stuhlinkontinenz
93
Paolo Abitabile, Christoph A. Maurer
94
Die Radiofrequenzablation erweitert das chirurgische Therapiespektrum von
Lebertumoren
swiss knife 2008; special edition Strength
through balance.
Balance the
power
– highly effective
in the prevention of
acute rejection … 1-3
… with
early halving
of CNI*
and good
renal function. 2-5
C: Tablet of 0.25, 0.5, 0.75, 1 mg everolimus. Dispersible tablet with 0.1, 0.25 mg everolimus. I: Prophylaxis of organ rejection in adult patients at low to moderate immunological risk receiving an allogenic renal or cardiac transplant, in combination with ciclosporin for microemulsion and corticosteroids.
D: Certican should only be prescribed by physicians who are experienced in immunosuppressive therapy. Adults: Initial dose regimen of 0.75 mg b.i.d. taken orally in two divided doses at the same time as ciclosporin for microemulsion. Dose adjustments based on blood levels achieved, tolerability,
individual response, clinical situation and change in co-medication at 4–5 d intervals. Routine blood level monitoring. For dose recommendations, hepatic impairment and dispersible tablets: see Compendium of Drugs. CI: Hypersensitivity to everolimus, sirolimus or one of the excipients. PC: Co-administration with CYP3A4-inhibitors and inducers. Exposure to UV light and sunlight. Antimicrobiological prophylaxis for Pneumocystis jiroveci (carinii) pneumonia for the first 12 months following transplantation, CMV prophylaxis for 3 months after transplantation. Hyperlipidemia. Monitoring of renal
function in all patients. Elevated serum creatinine levels: ciclosporin dose reduction should be considered. Rare hereditary problems of lactose intolerance, lactase deficiency or glucose-galactose malabsorbtion. Pregnancy: consider carefully risk/benefit; use effective contraception
method. Breast feed not recommended. UE: Very common: leucopenia, hypercholesterolemia, hyperlipidemia. Common: viral, bacterial or fungal infections, sepsis. Lymphoma, lymphoproliferative disease. Malignancies. Thrombocytopenia, anaemia, coagulopathy, thrombotic thrombocytopenic purpura/haemolytic uraemic syndrome. Hypertriglyceridemia. Hypertension, lymphocele (in renal transplantation), venous thromboembolism. Pneumonia. Acne, surgical wound complication. Urinary tract infection. Oedema. Pain. Uncommon: see Compendium of
Drugs. IA: Medicinal products affecting CYP3A4 and/or P-glycoprotein (PgP). Bioavailability of everolimus increased by co-administration of ciclosporin: dose adjustments for both medicinal products. Grapefruit and grapefruit juice. Vaccination; avoid live vaccines. P: Tablets of 0.25,
0.5, 0.75, 1 mg: 60. Dispersible tablets of 0.1, 0.25 mg: 60. Sale category: B. For further information, please consult the Swiss Compendium of Drugs. References: 1. Eisen HJ et al. Everolimus for the prevention of allograft rejection and vasculopathy in cardiac-transplant recipients. N Engl J Med 2003; 349: 847-858. 2. Tedesco-Silva H et al. 12-month safety and efficacy of everolimus with reduced exposure cyclosporine in de novo renal transplant recipients. Transplant Int 2007; 20: 27-36. 3. Vitko S et al. Everolimus (Certican) 12-month safety and
efficacy versus mycophenolate mofetil in de novo renal transplant recipients. Transplantation 2004; 78(10): 1532-1540. 4. Pascual J. Concentration-controlled everolimus (Certican): combination with reduced dose calcineurin inhibitors. Transplantation 2005; 79(3S): S76-S79.
5. Wang SS et al. Cyclosporine reduction in the presence of concentration-controlled everolimus in de novo cardiac transplantation: 6-month study results. Transplant Int 2007; 20(2S): 94, abstract O326. *Calcineurin inhibitor.
;%-%!'%%,
The confidence to get the balance right
Video Installation
Origin of Life
Videoinstallation von Ossi Robertson
www.ossirobertson.ch
„Origin of Life“ ist die neuste Videoinstallation des Videokünstlers Ossi
Robertson. Diese Installation verbindet in eindrücklicher Weise eine Video
installation mit zeitgenössischem, klassischem Tanz und psychodelischer
Musik zu einem vollendeten, inspirierenden und mitreissenden Kunstwerk:
Eine multimediale Collage vom Feinsten.
Die Videoinstallation wird im Foyer 2. Stock des Congress Center Basel
während des Kongresses permanent vorgeführt.
Videostill aus «Origin of Life» 2008, Ossi Robertson
ZUM GESAMTWERK
Ausstellungen und Kooperationen
Das Gesamtwerk umfasst thematisch zwei Teile: Die Body Insights und die
Emotionen zwischen «Leben – Mensch – Sinn».
Body Insights
Bei seinen «Body Insights» erschafft Ossi Robertson als Künstler der
Endoskopie spannungsreiche Bildformen zwischen Medizin und Kunst. Er
erzählt kleine Geschichten, um die Aufmerksamkeit auf die innere Schönheit
des menschlichen Körpers zu lenken. Robertsons Werkserie «Body Insights
– When Human Body Becomes Art» hat der Kunstkritiker Paolo Bianchi in
einem ausführlichen Essay treffend als «Operation Video oder von der medizinischen Aktion zum künstlerischen Akt» beschrieben
(siehe www.ossirobertson.ch unter «Kritik»).
Emotionen zwischen «Leben – Mensch – Sinn»
Bei diesen Werken von Ossi Robertson steht die Emotion im Mittelpunkt.
Obschon Videostills bloss Bilder für an die Wand darstellen, schafft es der
Künstler mit seinen Videostill-Emotionen einen «Film» zu zeigen, der durch
Unschärfe und Dynamik der Bilder fasziniert, umso mehr als Robertsons Arbeiten zusätzlich mit Acryl bemalt sind. Mit diesen emotionalen Bildwelten
verleiht Robertson dem Leben als Ganzes und dem einzelnen Menschen
darin einen eigenen Sinn. Diese Kunst des Eigensinns führt zu einem Gestaltungswillen, der alles rund um das Kommen und Gehen auf dieser Welt thematisiert: Endlich- und Unendlichkeit, Beschränkung und Verschwendung,
Ordnung und Chaos, Absicht und Trieb, Respekt und Provokation, Sicherheit
und Zweifel. Der Zugriff auf die Inhalte erfolgt mit chirurgischer Präzision und
Hightech-Instrumenten. Die künstlerische Kreation ist vulkanisch. Was im Urgrund der eigenen Welterfahrung liegt, brodelt an die Oberfläche. Die Präsentationsform der Videostill-Emotionen ist vielfältig und grosszügig.
1995 Ausstellung Kongresshaus Davos: «2 Leinwandtechnik»: Hysterectomy, C-Section (Serie 0)
2004 Mitarbeit am Projekt «Stir Heart, Rinse Heart» von Pipilotti Rist,
SFMOMA, San Francisco
2005 Videoinstallation für Tanztheater «Solo Nr. 11» von Denise
Lampart, Film als Hinterprojektion und Installation im Theater
Rigiblick, Zürich
2005 Mitarbeit am Projekt «homo sapiens sapiens» von Pipilotti Rist
für Biennale Venedig, Kirche San Stae
2005 Ausstellung des Videos «Die 12 Höhlen des Löwen» im Olympus
Headquarter, Hamburg und an europäischen Kongressen 2005
bis 2007
2006 Ausstellung Body Insights Videostills, Warteräume an der Rämi–
strasse 35 in Zürich
2007 Outside-IN: Installation am 600 Quadratmeter-Messestand von
Enzo Enea, Giardina Zürich und Hamburg
2007 Videostills - Emotionen: Ausstellung von «Non-Body Insights» in
der Galerie Claudine Hohl in Zürich
2008 Videoinstallation «Origin of Life» wird in Peking uraufgeführt
Claudine Hohl
swiss knife 2008; special edition Congress Topics
Surgical Research: Shaping Tomorrow’s Therapies
Giulio Spagnoli, gspagnoli@uhbs.ch
Ivan Martin, imartin@uhbs.ch
Andrea Banfi, abanfi@uhbs.ch
Michael Heberer, mheberer@uhbs.ch
Gone are the days of research as a luxury hobby of an enlightened minority
of doctors visiting labs during time free of clinical duties. These pioneers did
not waste their time: a number of major advances in basic science and clinical
practice ranging from HLA discovery to unravelling of angiogenesis mechanisms derive from their efforts. Dr. Judah Folkman (1933-2008) provided the
best example of an accomplished, practicing surgeon, who single-handedly
created the field of tumor angiogenesis, which saw its first FDA-approved
treatment last year.
Nowadays, professional scientists with long years of bench experience, frequently focused on highly specific models, usually run the game in clinical
research labs. A number of them have never seen a „real” patient. The gap
between clinical and scientific expertise appears to grow larger every day.
It would be tempting to conclude that it cannot be bridged and assume as
inevitable the distinction between „us” and „them”, irrespective from which
side you wish to be located. It would be a mistake.
Science and clinical activity need each other more than ever. On one hand,
the identification of clinically relevant targets for their research represents the
dream of many basic scientists. On the other hand, surgery definitely benefits
from a refined knowledge of biological mechanisms providing a solid scientific background to the daily decision making. To generate a productive biomedical culture from such disparate backgrounds is an important daily task
for researchers in surgery. The enthusiasm of young surgeons for research is
precious fuel for this effort. But the young surgeon researcher faces a number
of hurdles ranging between limited time and the continuing demands of clinical education. Heads of clinical institutions and hospital administrators must
support the young scientific talents by appreciation and formal recognition of
their contributions.
Giulio Spagnoli
Ivan Martin
Here in Basel, strange characters have developed. Some surgeons and PhDs
together constructed recombinant vaccinia viruses encoding tumor associated antigen and co-stimulatory molecules to be used in active specific
immunotherapy (e.g. vaccination) of metastatic melanoma. Other surgeons
injected theses viruses into patients and monitored their HLA class I restricted
immune response as well as their clinical response. PhDs with a special interest in prognostic criteria of NSCLC and prostate malignancies can be met
in the cafeteria, chatting with young surgeons also about virtues and drawbacks of common receptor chain cytokines in the development of memory
cytotoxic T lymphocyte response. Other surgeons here in Basel were involved
in the identification of strategic research areas in regenerative medicine (i.e.
musculoskeletal tissue engineering or cell and gene therapy for therapeutic
angiogenesis) and contributed to the research in close cooperation with dedicated scientists. These groups are scientifically productive, have gained international recognition and continue to raise considerable amounts of funding.
They prove that the interaction of surgeons and scientists is the most relevant
success factor of surgical research.
The development of a common cultural background between surgery and
basic sciences represents a critical success factor for surgical research and
the development of the surgical disciplines. We are convinced that the contribution of young surgeons not only leads to the development of science
and enables clinical translation of innovation but also benefits their surgical
careers.
Andrea Banfi
Michael Heberer
Congress Topics
Das Management von Polytraumapatienten: ATLS oder mehr?
Norbert Suhm, suhmn@uhbs.ch
Augustinus L. Jacob, jacoba@uhbs.ch
Marcel Jakob, mjakob@uhbs.ch
3D Rekonstruktionen vom Skelett
CT-Scout ap und seitlich
Das Trauma führt zur höchsten Sterblichkeit und Invaliditätsrate in der Schweiz
und weltweit in entwickelten Ländern bis zum 40. Lebensjahr. Ein relevanter
Anteil unserer schwerverletzten Patienten ist innerhalb der ersten Stunden
vom Tod, meist durch Kreislaufschock bedroht. Diese Patienten können von
einer schnellen und zielgerichteten Diagnostik und Therapie profitieren, die
das unmittelbare Überleben sichert. Es ist deshalb unabdingbar ein standardisiertes, prioritätenorientiertes Schockraummanagement für Traumapatien
ten anzuwenden.
Um ein weltweit akzeptiertes Behandlungs- und Ausbildungskonzept handelt
es sich beim „Advanced Trauma Life Support“ (ATLS®). 1998 in der Schweiz
eingeführt, hat es sich zur Standardbehandlung der Polytraumapatienten
entwickelt. Ziele sind die möglichst schnelle und genaue Einschätzung des
Zustandes (assessment), die prioritätenorientierte Behandlung (treat first
what kills first) auch ohne definitive Diagnostik und über allem der Gedanke,
Sekundärschäden zu vermeiden (do no further harm). Im Behandlungsalgorithmus ist die wiederholte klinische Beurteilung mit wenigen zusätzlichen Untersuchungen ein Eckpfeiler. Als bildgebende Untersuchungen während der
Reanimationsphase sind Nativaufnahmen (HWS lat., Thorax, Becken) sowie
eine abdominelle Ultraschalluntersuchung (Blutung, Perikarderguss) vorgesehen. Diese sind zwar einfach durchzuführen, nehmen aber wichtige Zeit in Anspruch. Die Aussagekraft für die Behandlung unmittelbar lebensbedrohlicher
Zustände ist zwar genügend, aber die geringe Sensitivität lässt auch wichtige
behandlungsbedürftige Zustände übersehen, so dass CT-Untersuchungen
praktisch immer noch angeschlossen werden (Kopf-Thorax-Abdomen).
Hinzu kommt, dass bei der Planung von CT-Fenstern innert weniger Sekunden ein so genannter „Scout“ gefahren wird, welcher Übersichtsbilder in der
Qualität von Röntgenbildern liefert und bereits eine Erstdiagnostik analog
zum Standardröntgen zulässt. Die Mehrschicht-Spiral-CT-Technik hat sich
als Untersuchung mit der höchsten Sensitivität für Weichteil- und Skelettverletzungen durchgesetzt und ermöglicht heute Ganzkörperuntersuchungen
innert weniger Minuten. Augenfällige Verletzungen können sofort, während
die Bilder am Monitor durchlaufen, diagnostiziert werden. Die detaillierte Analyse kann zwar ohne weiteres eine halbe Stunde in Anspruch nehmen, das
Norbert Suhm
Augustinus L. Jacob
behandelnde Team kann aber mit der weiteren Therapie, einschliesslich der
notwendigen Verlegung, fortfahren. Problematisch ist vielerorts die räumliche
Trennung von Schockraum und CT-Raum, die oft Transporte und immer mehrere Umlagerungen erfordern, was bei einem intubierten und „verkabelten“
Unfallopfer zeitraubend und risikoreich sein kann. Konsequenterweise fordern daher viele Unfallchirurgen den Einbau von CT-Geräten direkt in oder
unmittelbar neben dem Schockraum.
Die Vorteile der primären CT-Diagnostik konnten wir in einer prospektiven
randomisierten Studie an zwei Patientengruppen mit einem Polytrauma (ISS
> 16) aufzeigen. Das Management und die Indikation für zusätzliche Untersuchungen erfolgte bei beiden Gruppen streng nach ATLS-Kriterien. Die zusätzliche konventionelle Röntgendiagnostik wurde dagegen entweder nach
diesen Kriterien, oder aber direkt das Spiral-CT mit Scout (ohne konventionelle Zusatzuntersuchungen) verwendet. Bei dieser zweiten Gruppe erfolgte
das Schockraummanagement ausschliesslich direkt im CT-Raum (Multifunktionaler Bildgestützter Interventionsraum). Wir konnten zeigen, dass für die
Primärdiagnostik mit dem Spiral-CT sowohl die Patientensicherheit gewährleistet werden konnte als auch die Zeit bis zur Diagnose von relevanten, behandlungsbedürftigen Verletzungen signifikant (p < 0,05) (bis zu 16 Minuten)
verkürzt werden konnte.
Fazit
Die Computertomografie kann im Rahmen der Polytraumadiagnostik nicht
länger nur als diagnostische Modalität für besondere Fragestellungen gelten.
Vielmehr ist sie heute in der Lage, im Vergleich zur klassischen Diagnostik mit
Röntgen und Ultraschall detailliertere Informationen schneller zu liefern. Geeignete bildgestützte Interventionsräume, die eine primäre Behandlung und
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Congress Topics
Diagnostique et thérapie du traumatisme abdominal
Mauro Arigoni, mauro.arigoni@eoc.ch
Raffaele Rosso, raffaele.rosso@eoc.ch
Le traumatisme abdominal est une entité assez fréquente et souvent associé
à d’autres lésions. En effet l’abdomen est fréquemment touché chez les patients polytraumatisés avec un fréquence de 20 à 40%. En Europe les traumatismes abdominales fermés sont beaucoup plus fréquent que ceux ouverts
alors qu’aux États Unis le rapport est inversé.
L’importance de ce traumatisme est surtout du au risque mortel élevé qui en
est lié. Un diagnostique exact et rapide ainsi qu’une thérapie immédiate sont
donc primordiaux dans la gestion de ces patients.
Actuellement l’intérêt de la littérature se porte surtout sur les trois thèmes suivants
Diagnostique en urgence:
Le gold standard du diagnostique du traumatisme abdominal est sans aucun
doute la CT surtout pour les organes solides. Cet examen peut être utilisé
chez tous les patients hémodynamiquement stables. Pour ce qui concerne les
patients instables la question de l’examen idéal reste encore ouverte. En effet
ces patients ont besoin d’un diagnostique plus rapide pour pouvoir décidé la
procédure à suivre. Alors qu’en Europe l’écographie rapide (FAST) a pris fermement pied dans la gestion initiale du traumatisme abdominal il est à relever
qu’elle présente une sensitivité assez basse de 73-86% avec une spécificité
d’environ 98% pour détecter du liquide intra-abdominal libre. C’est une des
raison pour laquelle cet examen n’a pas encore remplacé le lavage péritonéal (DPL) aux États Unis. Le DPL en effet présente une meilleure sensitivité
(92-98%) dans la détection d’un hémopéritoine ou d’une lésion intestinale.
L’avantage de la FAST reste naturellement le fait d’être un examen non invasif alors que le DPL peut comporter des complications et avoir des résultats
faux positifs. Les défenseurs de la FAST ont démontré que cet examen peut
également être effectuer en phase pré-hospitalière avec une bonne précision.
De leur coté les défenseur du DPL ont développé un système d’aspiration
péritonéale avec un taux de complication très bas. Le débat reste donc ouvert
et il est donc encore légitime de procéder directement à une laparotomie
chez un patient hémodynamiquement instable avec une suspicion de lésion
intra-abdominale.
Le traitement conservateur peut être soutenu par des techniques radiologiques d’embolisation avec de bons résultats.
De plus en plus on tente également cette attitude pour les traumatisme ouvert
avec un certain succès.
Rôle de la laparoscopie:
Dès les années 90’ la laparoscopie a été utilisée dans la gestion du traumatisme abdominal sans pour autant s’être tout de suite établie. Actuellement
elle a surtout un rôle diagnostique dans les traumatismes ouvert pour exclure
une lésion du péritoine ou du diaphragme. Elle permet ainsi d’évité une laparotomie négative dans environ 65% des cas. Le rôle de la laparoscopie dans
le traumatisme fermé n’est pas encore clair en particulier à cause de la basse
sensitivité dans la détection de lésion intestinale comparé à la laparotomie.
D’un autre côté le taux de complications à la suite d’une laparoscopie négative reste très bas (1.3%).
Les extrémistes de la laparoscopie soutiennent que celle-ci est possible également chez des patients instables et que dans la plupart des cas la thérapie peut être effectuée sans passer par une laparotomie. D’autres proposent
l’utilisation de la laparoscopie en anesthésie locale pour exclure un lésion du
péritoine et ainsi pouvoir décharger le patient.
Pour conclure on peut dire que la gestion du traumatisme abdominal reste
un challenge et qu’elle nécessite l’utilisation adéquate d’une grande palette
d’outils diagnostiques et thérapeutiques.
Références
Rôle du traitement conservateur:
Jusque dans les années 1980 le traitement des traumatisme abdominaux fermés était agressif, ce qui portait à un taux élevé de laparotomie négative.
Après de bonnes expériences dans le traitement conservateur de traumatisme fermé avec lésion d’organe solides chez les enfants cette attitude a peu
à peu été adopté également chez les adultes. Cette thérapie n’est applicable qu’à des patients hémodynamiquement stables. Actuellement ce genre
de traitement présente un taux de succès de près de 65-90%. Les risques
d’échec de ce traitement sont les suivants: lésion de la rate ou du rein, FAST
positif pour liquide libre, volume > 300ml de liquide libre au CT et besoin de
transfusion. La présence des 4 facteurs de risque porte à un échec de traitement dans 96% des cas.
Mauro Arigoni
Griffin XL, Pullinger R. Are Diagnostic Peritoneal Lavage or Focused Abdominal Sonography for Trauma Safe Screening Investigations for Hemodynamically Stable Patients
After Blunt Abdominal Trauma? A Review of the Literature J Trauma. 2007; 62: 779–784
Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment
of blunt injury to solid abdominal organs: a prospective study. Arch Surg. 2003; 138(8):
844-51
Villavicencio RT, Aucar JA. Analysis of Laparoscopy in Trauma J Am Coll Surg 1999;
189: 11-20
Weinberg JA, Magnotti LJ, Edwards NM, Claridge JA, Gayle Minard G, Fabian TC, Croce
MA.‘‘Awake’’ laparoscopy for the evaluation of equivocal penetrating abdominal woundsInjury, Int. J. Care Injured 2007; 38: 60-64
Raffaele Rosso
swiss knife 2008; special edition 11
Fragmin Ins 210x148 dt
14.12.2006
13:22 Uhr
Seite 1
Antithrombotische Wirkung – einfach und zuverlässig
Fragmin: Breit einsetzbar
1
Zulassung in der
onkologischen Chirurgie
1
Verlängerte Prophylaxe reduziert
TVT-Inzidenz signifikant 2
NNT = 6
p < 0.005
Inzidenz einer TVT (%)
18
16
14
15.9%
12
10
8
6
4
2
0
0%
7 Tage TEP
28 Tage TEP
mit Fragmin (n = 63)
mit Fragmin (n = 54)
Referenzen: 1 Arzneimittel-Kompendium der Schweiz 2006 2 Rasmussen MS et al. Preventing thromboembolic complications in cancer patients after surgery: A role for prolonged thromboprophylaxis. Cancer Treat Rev 2002M 28:141-144.
Gekürzte Fachinformation Fragmin®
Wirkstoff: Dalteparin. Indikationen: Thromboembolieprophylaxe, u.a. Prophylaxe bei immobilisierten Patienten; Gerinnungshemmung während Hämodialyse/Hämofiltration; Therapie akuter tiefer Venenthrombosen; instabile koronare
Herzkrankheit. Dosierung: Thromboembolieprophylaxe: 2500-5000 IE s.c. 1x täglich; Patienten mit eingeschränkter Mobilität: 5000 IE s.c. 1x täglich während 12-14 Tagen oder länger; Gerinnungshemmung während Hämodialyse/
Hämofiltration: Bolusinjektion von 5’000 IE i.v. oder 30-40 IE/kg KG und anschliessend i.v. Infusion von 10-15 IE/kg KG/Std; akute tiefe Venenthrombosen: 200 IE/kg KG s.c. 1x täglich; instabile koronare Herzkrankheit: 120 IE/kg
KG s.c. 2x täglich kombiniert mit ASS. Kontraindikationen: Überempfindlichkeit auf Dalteparin/Heparine; schwere Gerinnungsstörungen; akute Magen-/Darmulzera; Hirnblutung; bakterielle Endokarditis; drohende Fehlgeburt; operative Eingriffe
am ZNS/Auge/Ohr; Regionalanästhesie bei Dosen >5000 IE/24 Std.; Mehrfach-Stechampulle: Schwangerschaft, Neu-/Frühgeborene (wegen Gehalt an Benzylalkohol). Vorsichtsmassnahmen: Thrombozytopenie, Thrombozytopathie, Leber-/
Pankreaserkrankungen, Niereninsuffizienz, unkontrollierte Hypertonie, hypertensive/diabetische Retinopathien; Behandlung akuter tiefer Venenthrombosen: Thrombozytenzählung erforderlich; hohe Dosen bei frisch operierten Patienten,
erhöhtes Blutungsrisiko bei gleichzeitiger thrombolytischer Behandlung, Entwicklung eines Spinal-/Epiduralhämatoms bei entsprechender Anästhesie, Untergewicht. Schwangerschaft/Stillzeit: Vorsicht
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ist geboten bei der Anwendung in der Schwangerschaft, da wenig klinische Erfahrung vorliegt. Abstillen wird empfohlen. Häufigste unerwünschte Wirkungen: Blutungen, Thrombozytopenie, Hämatome
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Congress Topics
Die Behandlung der Klavikulaschaftfrakturen –
Chirurgie wann und wie?
Corinne J. Geppert, corinne.geppert@ksa.ch
Nikolaus L. Renner, nikolaus.renner@ksa.ch
Klavikulafrakturen machen etwa 4 – 10% aller Frakturen im Erwachsenenalter
aus. Es handelt sich somit um relativ häufige Verletzungen. Ca. 80% betreffen
den Schaftbereich, ca. 15% das laterale und ca. 5% das mediale Ende.
Die heute am weitesten verbreitete konservative Behandlung mit einem Rucksackverband geht auf Lucas Championnière (1860) zurück. Allerdings können
damit die Fragmente nur bedingt in reponierter Stellung gehalten werden, so
dass es in der Regel zu einer Ausheilung in Verkürzung kommt. Diese führt
zwar nicht zu einer objektivierbaren funktionellen Einbusse, jedoch wurde von
verschiedenen Autoren eine Korrelation zwischen dem Ausmass der Verkürzung und der Persistenz von Beschwerden nachgewiesen. Der Schwellenwert scheint bei etwa 2 cm Verkürzung zu liegen. Pseudarthrosen kommen
bei konservativer Behandlung in 4,5 – 15% der Schaftfrakturen vor. Nicht
ganz zu vernachlässigen ist auch das kosmetische Resultat, welches von 30
– 50% der Patienten als nicht befriedigend eingestuft wird.
Die Plattenosteosynthese, erstmals in den 1960er Jahren beschrieben, galt
lange Zeit als Standardverfahren der operativen Behandlung. Als Implantate
setzten sich gerade Platten (DCP, LC-DCP) oder Rekonstruktions-Platten der
Dimension 3,5 durch. Im Vergleich zu diesen „konventionellen“ Platten bieten
die neueren winkelstabilen Platten-Schrauben-Verbindungen (LCP) den Vorteil der sichereren Fixation insbesondere im lateralen Bereich, wo der Knochen relativ dünn und eher weich ist. Unter Verweis auf kosmetische oder
biomechanische Vorteile wird von unterschiedlichen Autoren jeweils die ventrale oder kraniale Platzierung der Platte empfohlen.
Die biomechanische Beanspruchung der Klavikula wird sehr kontrovers diskutiert, so dass sich daraus keine eindeutige Empfehlung bezüglich der Plattenlage ableiten lässt. Auch die kosmetischen oder funktionellen Argumente
sind wenig überzeugend, da sich die Platten unabhängig von ihrer Lage häufig subkutan abzeichnen und beim Tragen von Lasten auf der Schulter stören.
Die Mehrzahl der Patienten wünscht deshalb im Verlauf die Entfernung des
Osteosynthesematerials. Wegen des Refrakturrisikos sollte diese frühestens
2 Jahre postoperativ erfolgen. Wir bevorzugen die kraniale Implantatlage aus
biologischen Gründen, weil die Platte dort ohne jegliches Ablösen von Muskulatur platziert werden kann. Als operative Zugänge stehen entweder der
infraklavikuläre Längszugang oder die quer verlaufende sog. „Coup de sab-
re“ Inzision zur Wahl. Letztere soll kosmetisch schönere Resultate liefern. Im
Vergleich zum Längszugang ist jedoch die Exposition medial und lateral behindert. Keinesfalls dürfen kosmetische Kompromisse dazu verleiten zu kurze
Platten zu verwenden. So sollten über jedem Hauptfragment 4 Plattenlöcher
liegen, welche jedoch – insbesondere bei LCP – nicht alle mit Schrauben
besetzt werden müssen. Die in der Literatur angegeben Pseudarthroserate
liegt bei 2,5 – 10%.
Als Alternative zur Plattenosteosynthese wurde von Rehm et al. 2004 die
intramedulläre Schienung mit elastischen Titan-Nägeln (TEN) von 2,0 bis
3,5 mm Durchmesser beschrieben. Der TEN wird hierbei durch eine kleine
Längsinzision von antero-medial her eingebracht und über die Fraktur so weit
wie möglich ins laterale Hauptfragment vorgeschoben. Die geschlossene Reposition gelingt zwar nur in ca. 50% der Fälle. Im Bedarfsfall genügt für die
Reposition jedoch eine kurze Querinzision über der Fraktur. Die kosmetische
Beeinträchtigung ist somit wesentlich geringer als bei der Plattenosteosynthese. Anfänglich wurde diese minimalinvasive Methode deshalb beinahe
kritiklos propagiert. Insbesondere nachdem eine vergleichende Studie die
Vorteile der intramedullären Osteosynthese gegenüber der konservativen
Therapien gezeigt hatte mit einer kürzeren Arbeitsunfähigkeitsdauer, einer
geringeren Komplikationsrate (Pseudarthroseraten < 1.6%), einer besseren
Schulterfunktion und besseren kosmetischen Resultaten. Die Erfahrung der
letzten Jahre zeigte jedoch auch zunehmend die Limitationen. Da sich der
TEN nur durch die gekrümmte Form der Klavikula verklemmt, lässt sich eine
axiale Verkürzung bei mehrfragmentären Frakturen nicht zuverlässig vermeiden. Das Verfahren eignet sich somit vor allem für einfache Frakturen.
Als Operationsindikation werden offene Frakturen, drohende Hautperforatio
nen, neurovaskuläre Zusatzverletzungen und Pseudarthrosen allgemein an
erkannt. Kontrovers diskutiert wird die Operationsindikation bei Kettenver
letzungen (ipsilaterale Frakturen oder Luxationen der oberen Extremität),
Klavikulafraktur bei Polytrauma, Refrakturen und einer initialen Verkürzung
von > 2 cm. Aufgrund der oben geschilderten Vorteile gegenüber der konser
vativen Behandlung sollte heute jedoch die intramedulläre Schienung grund
sätzlich jedem Patienten mit einer dislozierten Fraktur wenigstens angeboten
werden.
® 2007 Ethicon Endo-Surgery (Europe) GmbH. All rights reserved.
ENDOPATH and Echelon are trademarks of Ethicon Endo-Surgery, Inc.
Congress Topics
Osteosynthese bei Osteoporose: Immer LCP?
Anja Grosskreutz, anja.grosskreutz@spitalfmi.ch
Dominik Heim, dominik.heim@spitalfmi.ch
Frakturen beim osteoporotischen Knochen sind traumatologische Knacknüsse. Sie werden uns in Zukunft wegen der zunehmenden Lebenserwartung
noch vermehrt beschäftigen. Dazu wurden neue Fixationskonzepte mit neuen
Implantaten entwickelt, zum Beispiel die LCP (locking compression plate). Sie
lässt die Wahl zwischen Kompression, winkelstabiler Verriegelung oder Kombination beider Verfahren. Die Platte kann nicht mehr nur am Knochen durch
die Reibung zwischen Implantat und Knochenoberfläche fixiert werden, sondern Platte und Schraube bilden mit ihren winkelstabilen Gewindeschraubenköpfen im Gewinde des Plattenloches eine Einheit im Sinne eines Fixateur
interne. Und das hat Erfolg! Wir kennen das Modell der Philosplatte am Apfel
von R. Frigg, bei dem eher der Apfel ausreisst, als dass man die winkelstabile
Platte am Apfel ausreissen kann. Und so wurde die winkelstabile Platte zum
Implantat der Wahl beim weichen, osteoporotischen Knochen1.
Der intramedulläre Marknagel wurde in den letzten Jahren zum Implantat der
Wahl im diaphysären Bereich und stiess zunehmend in den metaphysären
Bereich vor. Damit tritt er nun aber in Konkurrenz mit den winkelstabilen
Platten, die den gelenknahen Bereich wieder „für sich beanspruchen“. Beim
Überblicken dieser Entwicklung fühlt man sich an den alpinen Wintersport
erinnert: Das Snowboarden schien in den 1990er Jahren zu einem unwiderstehlichen Boom zu werden. Da entwickelte die Skiindustrie den Carving Ski
– die Snowboardindustrie stagnierte2.
Die Folge der winkelstabilen Revolution war eine Flut von neuen Implantaten
und Formplatten. Und das kann – je nach Ressourcen der behandelnden Institution – zu ökonomischen Engpässen führen. In der postprimären Situation
können gewünschte Systeme/Implantate beim Produzenten bestellt werden,
in der Notfallsituation gilt es Alternativen zu kennen.
Auch andere Aspekte gilt es in der LCP-Euphorie (die wir durchaus – am
proximalen und distalen Humerus, vor allem am distalen Radius, aber auch
am distalen Femur und an der proximalen Tibia-LISS – teilen) noch zu berücksichtigen: Die mit einem winkelstabilen Implantat fixierte Fraktur/Osteotomie
kann so rigide fixiert sein, dass es zu „Re“frakturen am Rand der Platte kommen kann (das Problem kann häufig mit einer längeren Platte gelöst werden).
Ein weiteres Problem kann die Metallentfernung darstellen, die wir zwar an
der oberen Extremität nur ausnahmsweise, an der unteren Extremität jedoch
noch häufig vornehmen, auch wenn die routinemässige Metallentfernung in
der letzten Zeit zu einer gesundheitspolitischen Frage der nationalen Ressourcen geworden ist3. Eine Metallentfernung, die länger als die ursprüngliche Implantatimplantation dauert, ist der Alptraum jedes Chirurgen. Man
schrieb dieses Phänomen der sogenannten Kaltverschweissung der Gewinde zu, jüngste Untersuchungen deuten jedoch eher auf ein Problem mit der
Osteointegration der Schrauben hin4.
Abb. 1: Drittelrohrhakenplatte am
Malleolus lateralis
Abb. 2: Drittelrohrhakenplatte bei einer
Olecranonfraktur
Die präoperative Frage ist deshalb weniger „Welche LCP nehmen wir?“ als
„Braucht die vorliegende Situation eine LCP oder gibt es auch Alternativen?“.
Eine davon könnte die Drittelrohrhakenplatte bei gelenknahen Frakturen sein,
die jeden Ökonomen begeistern dürfte (Abb. 1 und 2). Diese Hakenplatte
kann ad hoc auch mit konventionellen Implantaten anderer Dimensionen
produziert werden5. Und bei guter Knochenqualität können auch weiterhin
konventionelle Implantate verwendet werden.
Die winkelstabilen Implantate sind die adäquate Antwort auf die zunehmend
osteoporotischen Fraktursituationen des 21. Jahrhunderts. Sie haben die
Frakturbehandlung revolutioniert und sind zu einem unentbehrlichen Helfer
in der Traumatologie geworden. Ihr Einsatz bedarf aber einer differenzierten
Indikation und Alternativen sollten aus ökonomischen, logistischen und patientenbezogenen Gründen in die Indikationsstellung miteinbezogen werden.
Literatur
1. AO Manual of fracture management, Internal Fixators. Ed. Wagner M, Frigg R. Thieme
2006
2. Hörterer H. Carvingskifahren. Orthopäde 2005; 34: 426-432
3. Busam ML, Esther RJ, Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg 2006; 14 (2): 113-20
4. Richards GR. Implant surfaces: Do they have any relevance to the surgeon. AO Dialogue 2007; 1: 20-29
5. Heim D, Niederhauser K. Die Drittelrohrhakenplatte. Oper Orthop Traumatol 2007; 3:
305-309
w w w. n a m b e . c h
03
Visceral Surgery
3.1
Welche Faktoren beeinflussen die gesundheitsbezogene Lebensqualität (HRQL) nach kontinenzerhaltender Rektumresektion?
J. Schuld, M.K. Bolli, M.K. Schilling (Homburg-Saar/DE)
Objective: Verminderte Lokalrezidivraten nach Einführung der totalen mesorektalen Exzision (TME) und
neoadjuvanter Therapieprotokolle haben dazu geführt, dass die Anzahl überlebender Patienten mit Rektumkarzinom innerhalb der letzten Jahre stark zugenommen hat. Das Rektumkarzinom per se, aber auch
die Folgen des operativen Eingriffes können die postoperative Stuhl-, Miktions- und Sexualfunktion erheblich beeinflussen. Deshalb ist es notwendig zu untersuchen, in wieweit derartige Störungen die gesundheitsbezogene Lebensqualität (HRQL) der Patienten im Langzeitverlauf beeinflussen.
Methods: Ein retrospektives Kollektiv aus 73 Patienten (48 m, 25 w) wurde im Mittel 1,9 Jahre nach kontinenzerhaltender Rektumresektion nachuntersucht. Alle Patienten erhielten standardisierte Fragebögen
zur Stuhl-, Miktions-, Sexualfunktion sowie zur gesundheitsbezogenen Lebensqualität (EORTC QLQ 30,
SF-36). Die so erhobenen Daten wurden miteinander korreliert.
Results: Im Vergleich zu einer Normstichprobe war im SF-36 die HRQL in allen Dimensionen vermindert,
signifikant hinsichtlich der körperlichen Funktionsfähigkeit, der körperlichen Rollenfunktion, der emotionalen Rollenfunktionen und des allgemeinen Gesundheitszustandes. Im EORTC korrelierte die Globaleinschätzung der HRQL mehr mit dem funktionellem Status und dem emotionalem Befinden als mit Durchfall oder Verstopfung. Im Vergleich der Geschlechter litten Frauen mehr an Schlaflosigkeit, Männer mehr
unter finanzieller Belastung. Weder die Zeitdauer zur zurückliegenden Operation (>12 und < 12 Monate),
noch die Höhe der Anastomose (anteriore Resektion mit PME vs. tief anteriore Resektion mit TME), das
Tumorstadium, das Auftreten einer Anastomoseninsuffizienz oder die Durchführung einer neoadjuvanten
bzw. adjuvanten Therapie beinflussten die HRQL im Langzeitverlauf. Die Anlage eines protektiven Stomas
zeigte nur im EORTC-QLQ 30 eine signifikant geringere Globaleinschätzung, geringe Arbeitsfähigkeit und
einen geringeren kognitiven Status. Eine schlechte postoperative Miktionsfunktion beeinflusste den funktionellen Status, die Arbeitsfähigkeit und den sozialen Status im EORTC-QLQ 30, während sich wiederum
im SF-36 keinerlei Unterschiede abbildeten. Eine beeinträchtigte Sexualfunktion war vergesellschaftet mit
Kurzatmigkeit und Appetitlosigkeit, führte im EORTC-QLQ 30 zu einem geringeren funktionellen Status und
im SF-36 zu einer schlechteren sozialen Funktionsfähigkeit.
Conclusion: Die postoperative Lebensqualität nach kontinenzerhaltender Rektumresektion wird im Langzeitverlauf deutlich durch die verminderte physische Konstitution eingeschränkt, wobei sich bei Frauen im
Vergleich zu Männern die Krankheitsverarbeitung mehr im emotionalen Bereich auswirkt. Schlaflosigkeit,
Müdigkeit, Schmerzen und Kurzatmigkeit spielen eine viel wichtigere Rolle für die HRQL als die Stuhlfrequenz oder Durchfall. Insgesamt bildeten sich im EORTC-QLQ 30 Unterschiede mehr ab als im SF-36.
3.2
Macht die rektale Endosonografie nach neoadjuvanter Vorbehandlung einen Sinn, insbesondere zur
Erkennung der kompletten Remission?
P. Meyer, U. Metzger (Zürich)
Objective: Wie hoch ist die Treffsicherheit der rektalen Endosonografie beim vorbehandelten Rektumkarzinom bezüglich yuT und yuN zur definitiven Histologie nach der (y)pTNM Klassifikation und wie verhält
sich die Treffsicherheit in der Subgruppe ypT0ypN0?
Methods: In einer prospektiven Phase-II Studie wurden Patienten mit einem Rektum-Karzinom Tumorstadium UICC II/III neoadjuvant vorbehandelt (5-FU/45Gy), präoperativ erfolgte nochmals eine Endosonografie durch 2 erfahrene Untersucher.
Results: 20 von 135 Patienten (14.8%) zeigten histologisch eine komplette Remission. T-Stadium:
EUS Richtig Understaged Overstaged N-Stadium:
EUS Richtig Understaged Overstaged Anzahl 63 29 43 Total 135 135 135 %
46.7 21.5 31.9 yuT0=ypT0(%)
15
0
85
Anzahl 79 23 33 Total 135 135 135 %
58.5 17.0 24.4 yuN0=ypN0(%)
80
0
20
Conclusion: Das Restaging mittels rektaler Endosonografie nach neoadjuvanter Vorbehandlung zeigt
eine geringe Treffsicherheit und ein vermehrtes Overstaging. In der Subgruppe der Patienten mit kompletter Remission ist die Vorhersage noch ungenauer. Aufgrund der postaktinischen Fibrosierung und der
daraus resultierend erhöhten Echogenizität ist die Beurteilung insbesondere des T-Stadiums erheblich
erschwert.
3.3
Is a sustaining rod necessary for diverting loop ileostomy?
V. Banz1, L.E. Brügger1, C. Egloff2, H. Gelpke1, M. Decurtins2, D. Candinas1 (1Bern, 2Winterthur)
Objective: Whether or not a protective stoma reduces the rate of anastomotic leakage after distal colorectal anastomosis is still discussed controversially. It does however facilitate clinical management once
leakage has occurred. Loop ileostomies seem to be associated with a lower morbidity and a better quality
of life compared to loop colostomies. Generally, diverting loop ileostomies are secured at skin level by
means of a supporting device in order to prevent retraction of the ileostomy into the abdomen. However,
due to the supporting rod, difficulties may occur in applying a stoma bag correctly and leakage of faeces
onto the skin may occur even with correct eversion of the afferent limb. Our aim was to compare morbidity
and time to self-sufficient stoma-care in patients having a loop ileostomy with rod to those without rod.
Methods: A total of 60 patients necessitating loop ileostomy were analyzed. Patients received surgery in
of the two involved institutions according to in-house standard procedures. 30 patients had an ileostomy
with rod (VCHK Inselspital) and a further 30 without rod (KSW Winterthur). Morbidity and time to selfsufficiency regarding stoma care was analyzed during the first 90 postoperative days. Morbidity was
determined according to a scoring system ranging from 0 to 4 points for any given set of possible complications (bleeding, necrosis, skin irritation, abscess, stenosis, retraction, fistula, prolapse, parastomal
hernia, incomplete diversion), where 0= no complication and 4= severe complication. Continuous variables were expressed as median (95% Confidence Interval). For comparisons between the groups the
Mann-Whitney U test was used, between categorical variables the X2 test was applied.
Results:
Age (years) Gender (male/female) Emergency operation Diabetes Hospital stay (days) Morbidity (total score) Stoma related reoperations Patients able to empty bag - Time needed (days) Patients able to change bag - Time needed (days) Patients able to change plate - Time needed (days) with rod (n=3) 58.5 (53-64) 17/13 13 3
18 (16-23) 3.5 (1-6) 3
28 12 (7-13) 20 11 (7-13) 17 13 (11-17) rodless (n=3) 63 (57-69) 16/14 11 7
19.5 (16-27) 3 (2-4) 0
27 10 (7-13) 26 12.5 (11-19) 24 13 (11-19) p
0.21
0.42
.6
.17
.69
.5
.08
.64
.38
.07
.14
.05
.88
There were no significant differences in length of hospital stay or time to self-sufficient stoma-care
between the groups. Although not significant, patients with a rod ileostomy had a tendency towards more
stoma-related complications as well as stoma-related reoperations. The number of patients reaching total
self-sufficiency regarding stoma care was higher after rodless ileostomy.
Conclusion: According to our data, rodless ileostomies seem to fare just as well as those with a supporting rod, with equal morbidity rates and more patients reaching self-sufficient stoma care. Therefore
routine application of a rod for diverting loop ileostomy seems unnecessary.
3.4
Longterm outcome after pathologically complete response (pCR) in multimodality treatment of rectal
cancer patients
A. Schnider, H. Honegger, N. Lombriser, P. Komminoth, U. Metzger (Zürich)
Objective: Longterm neoadjuvant chemoradiation of locally advanced low rectal cancer patients has become a strategy to further improve the outcome of patients. This report analyses the longterm follow- up
of patients with pCR.
Methods: 149 neoadjuvant treated rectal cancer patients (male/female 110/39; median age 62) undergoing surgery at our institution from 9/95 to 12/07 were analysed. Either 5-Flurouracil or Capecitabine/Oxaliplatin concurrent with radiation in three-field technique in prone position (25x1,8Gy) was given.
Surgery was performed within 4-8weeks after completion of neoadjuvant treatment. We evaluated complications, overall survival (OS) and disease-free-survival (DFS) in patients with pCR.
Results: PCR rate was 13,5% (20/149). 50% (N=75) got a partial response, 21.5% (N=32) had stable
disease and 15% (N=22)had progression. Pretreatment staging (EUS/CT) in these 20 patients: 2 had
T2N0, 4 had T2N+, 4 had T3N0, 9 had T3N+ and 1 had T4N+. LAR was done in 15 patients, 2 had APR
and in 3 full thickness excision was done only. Median hospital stay was 16 days. Complications occurred
in 5 (25%) patients, no mortality was observed. All patients with a minimal follow-up of 2 years are still
alive and without any local or distant recurrence.
Conclusion: Pathologically CR is a prognostic factor for a good longterm disease-free and overall survival
compared to non-CR patients in our series. These data indicate that some highly selected patients may
profit of a simple transanal local excision with adequate oncological longterm results and without surgical morbidity. Better pretreatment and preoperative staging procedures have to be evaluated to select
better these patients.
3.5
Surgical complications after neoadjuvant treatment in low rectal cancer patients: critical analysis
A. Schnider, N. Lombriser, H. Honegger, U. Metzger (Zürich)
Objective: This report evaluates the rate and outcome of surgical complications in low rectal cancer after
longterm radiochemotherapy in stage UICC II/III of a single center.
Methods: All neoadjuvant treated rectal cancer patients (N=149) from 9/1995 to 12/07 were analysed.
Either 5-Flurouracil or Capecitabine/Oxaliplatin concurrent with radiation in three-field technique in prone
position (25x1,8Gy) was given. Surgery was performed within 4-8weeks after completion of neoadjuvant
treatment.
Results: 149 patients (male/female: 110/39; median age 62) undergoing surgery at our institution
were analysed. The median distance of the tumour to the dentate line was 4,5cm. 117(79%) patients
got a sphincter saving procedure: 84(56%) low anterior resection with stapled anastomosis, 29(20%)
low anterior resection with handsewn transanal anastomosis, 4(3%) transanal full thickness resection.
30(20%)patients underwent abdominoperineal resection and 2(1%) patients total pelvine exenteration.
Histological complete response (CR) was 13,4% (20 patients). In-hospital-mortality was zero. 89 (60%)
patients had no complications. Clinical leakage rate was 16% (19/117). Presacral abscesses were observed in 20% (30/149). Reoperations were necessary in 19% (28/149). 5 patients suffered from major
17
problems because of routinely applied ileostomies, urological problems (N=5), wound infections (N=6)
prolonged gastric emptying (N=8). The impact of complications on survival will be discussed.
Conclusion: Our results indicate a benefit of neoadjuvant treatment concerning CR and sphincter saving.
But the severity of complications after longterm neoadjuvant radiochemotherapy in low rectal cancer
surgery should alert surgeons and oncologists. Further investigations should be done on more precise
pretreatment and preoperative staging to prevent overtreatment. Selected patients with assumed CR may
profit of simple transanal local excision to avoid major surgical complications.
3.6
Expression of p53 is not associated with tumor response to neoadjuvant radiochemotherapy for rectal
cancer
B. Kern, N. Devaux, U. Wagner, M. von Flüe (Basel)
Objective: Locally advanced rectal cancer is currently treated by neoadjuvant radiochemotherapy (RCT)
followed by surgery. Complete pathologic response can be achieved in up to 20-25%, but predictors for
pathologic complete response are currently unknown. The tumor suppressor gene p53 which regulates
the cell cycle and apoptosis has been proposed to play a role in tumor response to RCT. The aim of this
study was to examine the correlation between p53 expression before and tumor response after neodjuvant RCT.
Methods: This study included 51 patients with adenocarcinoma of the middle or lower rectum and stage
T3 or T4. All patients had neoadjuvant RCT with 50.4 Gy and Capecitabine. Tumor regression was graded
according to Dworak classification (grade 0-4). Paraffin-embedded tissue from the tumor obtained before
RCT was studied by immunohistochemical staining for p53. A semiquantitative grading system and the
immune reactive score (intensity grade multiplied with corresponding percentage of tumor cells) were
considered in the staining system.
Results: Pathologic complete response (ypT0 ypN0, Dworak 4) was achieved in 21%. Before RCT, p53
expression on tumor biopsies was positive in 40/51 cases (78%) and negative in 11/51 cases (22%).
Correlation of p53 and tumor response to RCT:
Dworak 0 N (%) Dworak 1 N (%) Dworak 2 N (%) Dworak 3 N (%) Dworak 4 N (%) Total N (%)
p53 + 1 (2) 10 (19) 16 (31) 6 (12) 7 (14) 40 (78)
p53 - 0 (0) 2 (4) 5 (10) 0 (0) 4 (8) 11 (22)
Conclusion: Immunhistochemical expression of p53 on rectal cancer cells before RCT is not a predictor of
tumor response and does not correlate with tumor regression grade after neoadjuvant RCT.
3.7
Long-term quality of life (QoL) after trimodality therapy for rectal cancer
M. Misirlic, A. Schnider, U. Metzger (Zürich)
Objective: Multimodality therapy and mesorectal excision have greatly improved the treatment of rectal
cancer. Thereby the evalutation of QoL after treatment is increasingly important. Our study measures global QoL and QoL concerning faecal incontinence, sexual disorders and urological problems in patients
with very low colorectal and coloanal anastomosis or definitive colostomy (APR).
Methods: 66 patients with rectal carcinoma were included in the study. Patients were treated in a trimodality setting, starting with neoadjuvant radio-chemotherapy (25 x 1.8 Gy, 5-FU at 100 mg/m2/24h at week
1 and 5) followed by resection 6 weeks later. QoL questionnaires were send to this 66 patients at a median follow up of 48 months. The return rate was 62 % (41/66). Internationally accepted questionnaires
were used: EORTC QLQC30, EORTC QLQCR38, CCIS, ipss, FSFI, IIEF in all patients.
Results: Considering the global health status, patients with coloanal (n=8) or APR (n=7) look upon their
health status more favourably than patients with low colorectal anastomosis. Patients after APR suffer
less physical impairment and are more stable emotionally compared to patients with coloanal anastomosis. These latter patiens have the lowest score in daily activity. Female patients (n=11) accomplish the
requirements of their everyday life with less impairment than their male counterparts (n=30). 44 % of all
patients with anastomosis have well to perfect continence. 63 % of patients with coloanal anastomosis
have severe incontinence, 23 % of patients with very low colorectal anastomosis. 64 % of all the patients
report none or only mild micturition symptoms. Patients after APR have the most impairment in general
sexual function and less frequent sexual intercourse, whereas patients with coloanal anastomosis have
the best sexual functioning score. 58 % of male patients suffer from erectile dysfunction.
Conclusion: QoL does not correlate directly with level of function. Patients after APR report being less
handicapped in everyday life and feel being more stable emotionally compared to patients after LAR.
Patients who are impaired by faecal incontinence fight a permanent invisible battle, whereas long-term
QoL in patients with definitive colostomy is improving by better coping and increases acceptance and
tolerance over time. The expected quality of life should influence the individual decision on which surgical
technique is to be chosen. Patients must be fully informed about the advantages /disadvantages of the
different techniques in terms of QoL in order to achieve a fully informed consent.
3.8
Serum tumor markers are not reliable predictors for the response to radiochemotherapy in rectal cancer
B. Kern, N. Devaux, U. Wagner, M. von Flüe (Basel)
Objective: Neoadjuvant radiochemotherapy (RCT) followed by surgery is currently used in patients with
locally advanced rectal cancer. Complete pathologic response can be achieved in up to 20%, but predictors for pathologic complete response (pCR) are currently unknown. Recent studies suggest, that serum
carcinoembryonic antigen (CEA) may be a predictor for the response to chemoradiotherapy. The aim of
this study was to evaluate if serum CEA and serum carbohydrate antigen 19-9 (CA19-9) correlate with
histologic stage and tumor regression grade after neoadjuvant radiochemotherapy in rectal cancer.
18
Methods: Sixty-two patients with an adenocarcinoma of the lower or middle third of the rectum and a
stage uT3 or uT4 were included in this prospective study. Serum CEA and CA19-9 were measured before
neoadjuvant radiochemotherapy. RCT was performed with 50.4 Gy and Capecitabine.Results were correlated with final histology (TNM-classification) and with tumor regression grade according to Dworak.
Results: Twenty-one percent of patients achieved a pCR with histologic stage ypT0 ypN0. Histologic stage
and regression grade were as follows: ypT0 21%, ypT1 10%, ypT2 26%, ypT3 43%; ypN0 79%, ypN+ 21%;
Dworak 0 2%, Dworak 1 26%, Dworak 2 37%, Dworak 3 16%, Dworak 4 19%. CEA was lower in patients
with good response to RCT (all ns.): 3.9µg/ml (ypT0) vs. 5.3 µg/ml (ypT3); 4.4 µg/ml (ypN0) vs. 7.3
µg/ml (ypN+); 3.6 µg/ml (Dworak 3-4) vs. 5.8 µg/ml (Dworak 0-2). For CA 19-9 results were better for
patients with good response to RCT, too (all ns.): 11 U/ml (ypT0) vs. 31.1 U/ml (ypT3); 13.2 U/ml (ypN0)
vs. 41.7 U/ml (ypN+); 11.5 U/ml (Dworak 3-4) vs. 24.1 U/ml (Dworak 0-2).
Conclusion: Patients with good or excellent response to RCT (ypT0, ypT1), no lymph node metastasis or
tumor regression grade 3 or 4 have lower values of serum tumor markers. As the results do not significant
differ, we can not confirm that CEA and CA 19-9 are predictors of tumor response in patients who receive
preoperative RCT for rectal cancer.
3.9
The sphincter’s fate in low lying rectum cancer: a decision analysis
M. Adamina1, M. Krahn2 (1Basel, 2Toronto/CA)
Objective: Abdominoperineal rectum resection (APR) is the standard oncological procedure for rectal
cancers located within 6 cm from the anal verge. Yet, APR entails a permanent colostomy. Intersphincteric
rectum resection (ISR) is an alternative surgical procedure which preserves the anal sphincter. However,
concerns about a less radical procedure translating in worse oncological results have precluded the widespread use of ISR. Owing to the harsh option of a permanent colostomy, a randomized controlled trial
is unlikely to address this clinical dilemma. Hence, a decision analysis was performed to balance the
strengths and trade-offs of APR and ISR and to rationalize the clinical decision-making.
Methods: A Markov process probabilistic model was built based on data from the Swedish Rectal Cancer
Registry (n=13’434) and on a published systematic review of the literature on ISR (n=1060). The base
case was a 65-year old patient with a stage II rectal cancer. The model was run for 35 years to account
for total life expectancy. Utilities representing 18 possible health states were derived from the literature and
integrated into the model, including early and late functional outcomes. Extensive sensitivity analysis was
performed on all clinical variables, together with two-way analysis for significant parameters. The main
outcome measures compared the quality adjusted life expectancy (QALY) and the crude survival rate of
rectal cancer patients undergoing APR or ISR.
Results: ISR was the preferred strategy with a significant gain of 1.13 QALY over APR (ISR 9.54 QALY
Vs APR 8.41 QALY). An effect size of 0.2 QALY or greater reflects a clinically meaningful difference. The
preference for ISR was not caused by a difference in crude survival, with both strategies displaying similar
5-year mortality rates (ISR 70.1% Vs APR 69.4%). Conversely, preference for ISR was sensitive to surgical
mortality and to the development of metastases, but neither to the development of local recurrence nor
of fecal incontinence. Remarkably, these results were robust to a broad range of colostomy utilities up to
a threshold value of 1 to prefer APR. Overall, the disutility of a permanent colostomy drove the preference
for ISR through the model.
Conclusion: Intersphincteric rectum resection is the preferred strategy for stage II rectal cancer patients.
This decision analysis systematically integrates the best available evidence for both APR and ISR strategies, thus contributing to informed clinical decision-making. Prospective research on the utilities of patients undergoing APR and ISR may further increase the strength of this conclusion.
04
4.1
Long-term results of laparoscopic total extraperitoneal hernia repair (TEP)
R.F. Stärkle, C. Buchli, P. Villiger (Chur)
Objective: There is growing evidence to suggest that, in the short-term, laparoscopic total extraperitoneal
hernia repair (TEP) is superior to the conventional Lichtenstein operation. However there is little information concerning the incidence of recurrence and development of chronic pain in the longer term. We report
the results of a nine-year follow-up in a single centre.
Methods: TEP was indicated in 107 male patients (mean age, 63 years) with primary bilateral, femoral or
recurrent inguinal hernia, operated on between July 1995 and April 2000 (including the learning curve).
The spermatic cord was isolated and enclosed in a heavyweight polypropylene mesh (12x15mm) with a
slit. The slit was closed anteriorly by overlapping mesh, secured with 3 staples. The patients completed a
questionnaire and were examined by independent surgeons after a mean follow of 116 months.
Results: In one case, a conversion to open surgery was necessary due to a major intraoperative complication. One patient developed obstruction of the small bowel in the postoperative period and needed
surgical revision. To date, 50 patients with 84 hernia repairs have been followed-up. The mean follow up is
116 (range, 91 – 148) months. There was a cumulative recurrence rate of 3.6%. 28% of the patients complained of some foreign body sensation. One patient developed chronic inguinal pain. The mean overall
satisfaction with surgical outcome was 9.1 (range, 0.3 to 10) on a visual analogue scale.
Conclusion: In this cohort, the long-term follow up showed a low incidence of recurrent hernia and chronic
inguinal pain. Subjective satisfaction with the outcome was very high.
4.2
4.4
Narbenhernien: Operationstechnik und Biotechnologie im Schatten der Risikofaktoren?
U. Dietz, M. Winkler, A. Thiede (Würzburg/DE)
Einfluss der Neurektomie auf postoperative Schmerzen bei der Hernienversorgung nach Lichtenstein
R. Lässker, F. Grieder, C. Cantieni, M. Decurtins (Winterthur)
Objective: Das Auftreten von Narbenhernien nach abdominellen Operationen ist ein bekanntes Phänomen. Die Datenlage der vergangenen Jahrzehnte zeigt, dass Narbenherniotomien durch direkte Naht
oder durch Fasziendoppelung nach Mayo mit Rezidiv-Raten um 40% einhergehen und nur noch in
Ausnahmefällen zu empfehlen sind. Durch Netzimplantationen als Bauchdeckenverstärkung oder auch
als Bauchdeckenersatz können die Rezidivraten je nach Technik auf 1-6% reduziert werden. Ein Blick in
die Literatur überflutet den Leser jedoch mit einer Vielzahl an Operationstechniken, seien sie offen oder
Laparoskopisch sowie einer Großzahl verschiedenster Netze. Eine einzige Technik kann kaum all den
Anforderungen gerecht werden. Ziel ist es, in einer retrospektiven Analyse des eigenen Patientenkollektivs
anhand einer neuen Narbenhernienklassifikation Kriterien für einen differenzierten Behandlungsalgorithmus auszuarbeiten.
Methods: Von 1999-2005 wurden an der Chirurgischen Klinik I des Universitätsklinikums Würzburg
350 Patienten mit ventralen Hernien operiert. Die Narbenhernien dieser Patienten wurden retrsopektiv
neu klassifiziert. Kriterien der Klassifikation sind die Wertigkeit der Hernie (ob primär oder rezidivierend),
die Morphologie der Hernie (median, umbilikal, supra-pubisch, median mit engem sterokostalen Winkel,
subcostal, transversal, lumbal oder nicht klassifizierbar), die Grösse der Bruchpforte in cm und das Vorhandensein von Risikofaktoren. Die Zahl der Risikofaktoren wird mit 1-3 angegeben. Die Patienten wurden
über einen Frageboden oder durch Nachuntersuchung auf das aktuelle befinden und Beschwerden hin
evaluiert.
Results: Das mittlere Follow-up betraf 44 Monate, 93,92% der Patienten wurden erfasst. Von allen
ventralen Hernien waren 51% primäre Narbenbrüche und 30% rezidivierte Narbenbrüche. 37% der Narbenrüche waren median und weitere 21% ausschliesslich umbilikal. Bei 12% kam es zu Serom- oder
Hämatombildung, bei 5% zu Wundheilungsstörungen, postoperative Bauchdeckenschmerzen traten
vorübergehend bei 16% auf. Die Rezidiv-Rate war bei den Nahtverfahren (Direktnaht, Fasziendoppelung
nach Mayo und Cutisplastik) signifikant höher als bei den Verfahren mit Netzimplantation (p=0,017). In
diesem Patientenkollektiv ist auffällig, dass bei 62% mehr als 3 Risikofaktoren vorhanden waren, bei 24%
zwei und bei 7% nur einer. Die Anzahl vorhandener Risikofaktoren korrelierte auch bei Netzimplantation
mit einer höheren Rerezidiv-Rate. Bei 3 oder mehr Risikofaktoren wurden 26,73% Rerezidive gegen 8,40%
bei 2 oder weniger beobachtet (p<0,05).
Conclusion: Anhand der vorgestellten Narbenhernienklassifikation sowie unter Berücksichtigung der
Risifokaktoren und der verschiedenen Operationstechniken wird ein neuer Behandlungsalgorithmus
vorgestellt. Bei medianen Narbenhernien mit der Möglichkeit der medianen Adaptation unter nur geringer Spannung sowie weniger als 3 Risikofaktoren wird die Bauchdeckenverstärkung mit Netz in SublayTechnik empfohlen. Bei hoher medianer Nahtspannung und allen weiteren Bruchmorphologien sowie
3 oder mehr Risikofaktoren wird der Bauchdeckenersatz als IPOM-Technik (offen oder laparoskopisch)
empfohlen. Da auch durch Netzimplantation gerade bei Risikopatienten keine Rezidivfreiheit erreicht wird
wäre denkbar, dass in Zukunft eine Risikotypisierung z.B. über den individuellen Kollagenmetabolismus
hifreich sein kann.
Objective: Postoperative Schmerzen nach Hernienversorgung sind ein bekanntes und in seltenen Fällen
hartnäckiges Problem. Im Rahmen einer ersten Auswertung einer laufenden prospektiven Datenerfassung an einem grossen schweizerischen Ausbildungsspital untersuchten wir den Zusammenhang der
Neurektomie des N. ilioinguinalis bei der Hernienversorgung nach Lichtenstein und das Auftreten von
postoperativen Schmerzen.
Methods: Wir haben alle Patienten eingeschlossen mit einseitigen oder beidseitigen Inguinalhernien, bei
denen zwischen Mai und November 2007 eine Inguinalhernienoperation nach Lichtenstein durchgeführt
wurde. Die Patienten wurden nach einem Monat kontrolliert und bezüglich Schmerzen, Rückkehr zur Arbeit und normaler Alltagstätigkeit ausgewertet.
Results: Es wurden 91 Männer und 4 Frauen mit einem Durchschnittsalter von 55.6 Jahren erfasst. In
23.2% wurde eine Neurektomie des N. ilioinguinalis durchgeführt (Gruppe A), bei 76.8% wurde der Nerv
belassen (Gruppe B). In der Gruppe A wurde ein durchschnittlicher postoperativer Schmerzindex (Skala
von 0 – 4) von 2.14 angegeben, in der Gruppe B ein solcher von 2.12. Nach 4 Wochen gab die Gruppe
A einen durchschnittlichen Wert von 0.73 und die Gruppe B einen von 0.55 an. Die Rückkehr zur Arbeit
war bei Gruppe A nach 16.4 Tagen und bei Gruppe B nach 14.1 Tagen möglich. Ein Taubheitsgefühl trat
in der Gruppe A in 59.1%, bei Gruppe B in 50.7% auf. In der Gruppe A waren 95.53% der Patienten nach
4 Wochen mit dem Ergebnis zufrieden, in der Gruppe B waren 98.6% zufrieden.
Conclusion: In unserer Patientengruppe war der postoperative Schmerz in beiden Gruppen gleich. 4 Wochen postoperativ waren die Schmerzen in der neurektomierten Gruppe leicht höher und es zeigte sich
eine leichte Zunahme des Taubheitsgefühles. Die Patientenzufriedenheit war in beiden Gruppen hoch. Im
Gegensatz zu einigen aktuell publizierten Artikel ist an Hand unserer ersten Auswertung eine prophylaktische Neurektomie bei der Hernienoperation nach Lichtenstein nicht indiziert.
4.3
Der Einfluss der intraoperativen Infiltration mit Lokalanästhetikum auf die Entwicklung von chronischen
Schmerzen nach Inguinalhernienrepair – Ergebnisse einer randomisierten, placebo-kontrollierten und
dreifach verblindeten Studie.
P. Honigmann1, H. Fischer1, A. Kurmann1, L. Audige2, G. Schüpfer1, J. Metzger1 (1Luzern, 2Davos)
Objective: In der Schweiz werden ca. 15‘000 Inguinalhernienoperationen pro Jahr durchgeführt, damit
ist diese OP eine der häufigsten Eingriffe. Das Hauptproblem besteht mittlerweile nicht mehr im Auftreten
von Rezidiven, sondern in der Entwicklung von chronischen Schmerzen (> 3 Monate postoperativ) unabhängig von der Operationstechnik.
Methods: Gemäss Protokoll sollten 240 Patienten, die sich einer elektiven Inguinalhernienoperation unterziehen in eine randomisierte, placebo-kontrollierte und dreifach verblindete Studie eingeschlossen
werden. Patienten der Gruppe I erhielten eine Injektion mit 20 ml Bupivacain 0.25% nach Verschluss der
Externusaponeurose nach einem standardisierten Verfahren. Patienten der Gruppe II erhielten eine Injektion mit Placebo (NaCl 0,9%). Hierfür werden bereits gefüllte, steril abgepackte, identisch aussehende,
blockrandomisierte und fortlaufend nummerierte Spritzen verwendet. Folgende Operationstechniken
wurden eingeschlossen: Lichtenstein, Barwell und TEP. Primäres Ziel der Studie war den Einfluss des intraoperativ gespritzen Lokalanästhetikums auf die Entwicklung von chronischen postoperativen Schmerzen
zu untersuchen. Die Schmerzen wurden mit Hilfe der VAS und des PainMatchers® gemessen. Durch ein
sequentielles Studiendesign basierend auf mehreren Interimsanalysen an zuvor festgelegten Zeitpunkten
sollte eine Fallzahlneuschätzung bzw. der vorzeitige Studienabbruch durchgeführt werden.
Results: Nachdem der 120. Patient die Nachkontrolle nach 3 Monaten durchlaufen hatte, wurden die geplante erste Interminanalyse von einer unabhängigen Organisation durchgeführt. Zwischen den beiden
Gruppen gab es keinen signifikanten Unterschied im Auftreten von chronischen Schmerzen nach 3 Monaten. Um ein signifikantes Ergebnis zu erreichen, hätten wir mehr als 200 Patienten pro Arm einschliessen
müssen. Gemäss Protokoll trat damit jedoch eine der beiden Abbruchkriterien in Kraft, so dass die Studie
zu diesem Zeitpunkt im Anschluss an ein Data Monitoring Committee abgebrochen wurde.
Conclusion: Wir konnten keinen Zusammenhang zwischen einer intraoperativen Infiltration mit Lokalanästhetikum und der Reduktion der Entwicklung chronischer postoperativer Schmerzen nachweisen.
Die Ergebnisse wären mit einer höheren Fallzahl signifikant gewesen. Aufgrund unserer Abbruchkriterien
musste die Studie jedoch beendet werden.
4.5
Use of fibrin glue (Tissucol®) in laparoscopic repair of abdominal wall defects: preliminary experience
S. Olmi, M. Misani, E. Croce (Milano/IT)
Objective: The aim of this study was to establish the efficacy and tolerability of human fibrin glue (Tissucol®) for the non-traumatic fixation of a composite prosthesis (Parietex®) in the laparoscopic repair of
small to medium incisional hernias and primary defects of the abdominal wall
Methods: From October 2003 to October 2007, 70 patients underwent laparoscopic repair at the hands
of one surgeon with expertise in laparoscopic surgery; all meshes were implanted in an intraperitoneal
position. Follow-up visits were scheduled for 7 days and 1, 6 and 12 months an 36. These included assessments for pain and postoperative complications.
Results: 70 patients (44 females, 26 males) with a mean age of 50 years (range 26 to 65) and a mean
BMI of 27 (range 25 to 30) were included in the study. 27 patients had incisional hernias, and 43 had
primary defects. The size of the defects varied from 2 to 7 cm. Adhesiolysis was necessary in 62,5% of
cases (55/70). There were no intraoperative complications or conversions. After a mean follow-up of 28
months (range 3 to 48), no postoperative complications were observed. The mean surgical intervention
time was 36 minutes (range 12 to 40) with an average hospitalization time of 1 day.
Conclusion: The use of fibrin glue provided stable and uniform fixation of the prosthesis and minimized
intra- and postoperative complications. Consequently, laparoscopic treatment of small to medium-sized
abdominal defects using this approach is our therapeutic option of choice.
4.6
Axillary lymph node dissection for sentinel lymph node micro-metastases can be safely omitted in early
breast cancer patients: long-term outcomes of a prospective observational study
I. Langer1, U. Güller2, C.T. Viehl2, H. Moch3, E. Wight2, D. Oertli2, M. Zuber4 (1Lausanne, 2Basel, 3Zürich,
4
Olten)
Objective: The sentinel lymph node (SLN) biopsy has emerged as the standard of care in evaluating the
axillary lymph node status in breast cancer patients. The use of step sectioning and immunohistochemistry in the SLN results in a more accurate histopathologic examination and a higher detection rate of
micro-metastases. The clinical relevance and therapeutic implications of SLN micro-metastases remain
controversial. The objective of this study was to evaluate the long-term outcome of all patients with SLN
micro-metastases, in whom a completion axillary lymph node dissection (ALND) was systematically
omitted.
Methods: In this prospective study, 236 SLN biopsies were performed in 234 early-stage breast cancer
patients (T1, T2≤3cm, cN0M0) between 1998 and 2002. The SLNs were examined by step sectioning
and stained with H&E and immunohistochemistry. None of the patients with negative SLN or SLN micrometastases (UICC: >0.2mm-≤2mm) underwent a completion ALND nor radiation to the axilla. Long-term
overall and disease-free survivals were compared between patients with negative SLN and those with
SLN micrometastases using the log-rank test.
Results: The SLN identification rate was 95% (224/236). The SLN was negative in 55% (123/224). SLN
micro-metastases were detected in 27 patients (27/224=12%). After a median follow-up of 77 months
(range 12-108) neither axillary recurrences nor distant metastases occurred in the 27 patients with SLN
micro-metastases. In the SLN negative group, one patient suffered from axillary recurrence and five from
distant metastases. There were no statistically significant differences neither in overall survival (p=0.572)
nor in axillary and distant disease-free survival (p=0.15) between patients with negative SLN and SLN
micro-metastases.
Conclusion: The present investigation provides compelling evidence that a completion ALND can be safely omitted in early stage breast cancer patients with SLN micro-metastases sparing the substantial morbidity of an ALND. This is based on the observation that none of the patients with SLN micro-metastases
experienced axillary or distant relapse after a median follow-up of over six years, the longest follow-up in
the literature.
19
4.7
Accuracy of frozen section analysis versus specimen radiography in breast conserving surgery for non
palpable lesions
S. Engelberger, W.P. Weber, C.T. Viehl, S. Kuster, S. Dirnhofer, D. Wruk, D. Oertli, W.R. Marti (Basel)
Objective: Specimen radiography (SR) is an established strategy for intraoperative resection margin analysis in breast conserving surgery for non-palpable lesions. By contrast, the use of frozen section analysis
(FSA) is still a matter of debate due to sampling errors and tissue artefacts of freezing, particularly in
procedures performed for ductal carcinoma in situ or atypical ductal hyperplasia.
Methods: One hundred and fifteen consecutive operations for non-palpable malignant lesions with the objective of breast conservation were retrospectively reviewed. Intraoperative resection margin analysis was
either performed by FSA or by SR. We evaluated the accuracy and therapeutic impact of FSA versus SR.
Results: In 111 female patients with 115 pTis, pT1 and pT2 non-palpable breast cancers, intraoperative
resection margin analysis was performed by FSA in 80 procedures and by SR in 35. Diagnostic accuracy,
sensitivity and specificity for FSA were 83.8%, 80% and 87.5%, respectively, as compared to 60%, 60%
and 60%, respectively, for SR. There was a trend toward a stronger therapeutic impact of FSA than of SR,
as assessed by the number of patients that had initial positive margins and were rendered margin-negative by intraoperative analysis and immediate re-excision or mastectomy (28% vs 14%; p= 0.124). This
clinically relevant trend was even more pronounced when we analyzed the 78 procedures performed
for ductal carcinoma in situ or atypical ductal hyperplasia (30% vs 13%; p = 0.083). Most importantly,
significantly less secondary re-excisions were performed in the FSA than in the SR series (13% vs 37%;
p=0.002). Finally, the use of FSA resulted in significantly less secondary procedures for axillary lymph
node staging because invasive cancer could be detected intraoperatively (5% vs 26%; p=0.001).
Conclusion: FSA seems to be more accurate than SR for intraoperative margin assessment in breast
conserving surgery for non-palpable lesions, regardless of the histopathologic feature of the lesion. FSA
significantly reduces the number of secondary re-excisions and secondary axillary lymph node staging
procedures.
4.8
Volume-controlled versus no/short-term drainage after axillary lymph node dissection in breast cancer
surgery: a meta-analysis
R.A. Droeser, D.M. Frey, A. Nordmann, D. Oertli (Basel)
Objective: It is unknown whether there are any clinically relevant differences between volume-controlled
vs no/short-term drainage after axillary lymph node dissection in breast cancer surgery on patient important outcomes such as seroma formation, wound infection or length of hospital stay.
Methods: We conducted a systematic literature search of Pubmed, EMBASE and the Cochrane library
using the search terms “axilla/(surgery)”, “axillary revision”, “breast neoplasms/(surgery)”, breast/
(surgery) or mammary”, “lymphadenectomy”, “drainage” and “random” to identify randomised controlled trials comparing no or short-term drainage (≤ 3 days) versus volume-controlled drainage (< 30-50
ml/24h across trials) after axillary lymph node dissection in breast cancer surgery. Trial data were reviewed and extracted independently by two reviewers in a standardised unblinded manner.
Results: Six randomised controlled trials including a total of 561 patients (299 patients randomised to
volume-controlled vs 262 patients randomised to no/short-term drainage) fulfilled our inclusion criteria.
Patients randomised to volume-controlled drainage were less likely to develop clinically relevant seromas
compared to patients randomised to no/short-term drainage (RR 0.44, 95% CI 0.24-0.80, p for heterogeneity < 0.001). There was, however, no difference in wound infections between patients treated with
volume-controlled drainage and patients with no or short-term drainage (RR 1.23, 95%CI 0.70-2.16, p
for heterogeneity = 0.8). Patients randomised to volume-controlled drainage stayed significantly longer
in hospital than patients randomised to no/short-term drainage (weighted mean difference 1.50, 95% CI
1.23-1.76, days, p for heterogeneity < 0.001).
Conclusion: Based on available evidence, clinically relevant seromas occur more frequently in patients
treated with no/short-term drainage. However, no/short-term drainage after axillary lymph node dissection does not lead to an increase in wound infections and is associated with shorter hospital stay.
05
5.1
Worse outcome in female patients after arthroscopic Bankart repair – gender related differences after
arthroscopic shoulder stabilisation
M. Kaipel1, S. Schützenberger2, J. Reichetseder2, M. Majewski1 (2Basel, 2Wien/AT)
Objective: Traumatic shoulder dislocation is a common injury with a life time prevalence of 2% often leading to recurrent joint dislocation and shoulder instability (figures in literature vary between 17 to 96%).
Predominately affected are young and active people suffering from the consequences of recurrent shoulder dislocations like chronic pain, decreased activity level and reduced quality of life. It is well understood
that human shoulder is mainly stabilized by muscles. Nevertheless intact ligaments and articular capsule
play an important role in preventing joint dislocation. Compared to males females posses minor muscle
strength and tend to exhibit increased joint laxity. Both factors could decrease shoulder stability and indicate an outstanding role for females concerning shoulder treatment. In the last decade arthroscopic
shoulder stabilization using Bankart’s repair technique became a standard intervention for traumatic anterior shoulder instability. Despite extensive literature on operation techniques and postoperative outcome
knowledge about gender related differences after arthroscopic shoulder stabilization is scarce. The aim
of our study was to compare the outcome of male and female patients with traumatic anterior shoulder
instability after arthroscopic Bankart repair.
Methods: We studied 22 male (mean age 29.2 years and mean follow up 55 months) and 12 female
patients (mean age 31.8 years and mean follow up 62.3 months). All patients underwent arthroscopic
shoulder stabilization due to anterior shoulder instability after traumatic shoulder dislocation. Patients
received a standardized questionnaire for evaluating subjective parameter. Subsequently patients were
clinically examined by orthopedic physicians where Constant Murley score was raised and Apprehension
test and Sulcus sign test was carried out.
Results: In our study female patients showed a significant lower Constant Murley score compared to
males (p=0.02). A positive Apprehension test indicating decreased shoulder stability was found more
often in females (p=0.05). Sulcus sign test indicating increased joint laxity was found in 25 % of female
and only 15% of male patients, without reaching statistical significance.
Conclusion: In our study female patients showed a worse outcome at a mean follow up of 62.3 months
after arthroscopic shoulder stabilization compared to males. Shoulder function as well as shoulder stability was significantly decreased in females indicating an outstanding role for female shoulder treatment
after traumatic joint dislocation.
5.2
Evolution of non-operatively treated supraspinatus tears
A.L. von Roll1, S. Fucentese2, C. Pfirrmann2, B. Jost2 (1Solothurn, 2Zürich)
4.9
Incidence of lymph node metastasis in papillary microcarcinoma of the thyroid
O.J. Wagner, S. Deyle, S.W. Schmid, S.A. Vorburger, D. Candinas, C.A. Seiler (Bern)
Objective: Thyroid microcarcinomas (PTMC), defined by the World Health Organization as less than 1.0
cm in size, are diagnosed with greater frequency. Furthermore PTMC’s are frequently most of the times
“incidentally” identified during initial surgery for benign thyroid disease or postoperatively during definite
histological workup. Despite the arguable “good” overall prognosis for patients with PTMC, these tumors
still are associated with lymph node metastasis which might lead to a higher recurrence rate and mortality. The primary aim of this study is to identify the rate of histologically positive lymph node metastasis
in PTMC.
Methods: Between 1995 and 2007, 65 patients (52 male and 13 female) with PTMC*, mean age at the
time of treatment 50 years (range, 20-81yrs), underwent thyroid surgery. Extent of surgery was based
on histological diagnosis provided either by intraoperative frozen section or rapid definitive histology. All
patients with intraoperative diagnosis of malignancy or bilateral nodular thyroid disease underwent at
least total thyreoidectomy (TR) (n=40). Thereof, modified neck dissection was additionally accomplished
during the same operation in 18 patients when rapid frozen section indicated malignancy. In 13 patients
with unclear intraoperative diagnosis, but malignancy in early definite workup (max 36h), completion thyreoidectomy (n=13) with modified neck dissection (MND) (n=10) or without MND (n=3) was performed.
In 12 patients a completion operation with thyreoidectomy and/or MND wasn`t performed because of
existing recurrent laryngeal nerve palsy or significant co-morbidity. *Data of all patients was collected
prospectively but evaluated retrospectively.
Results: Out of 65 patients with papillary thyroid microcarcinoma, 28 underwent modified neck dissec-
20
tion during initial or early completion surgery. Mean number of dissected lymph nodes was 33/MND. Histological workup revealed lymph node metastases in 10 patients (36%), whereas 18 patients (64%) were
free of lymphatic tumor spread. 6 patients (60%) with positive lymph node metastases had a multifocal
and 4 (40%) had a solitary PTMC tumor. In contrast, 10 patients without positive lymph node metastases
had a multifocal (56%) and 8 (44%) a solitary PTMC.
Conclusion: Our data clearly shows that well-differentiated papillary microcarcinomas, less than 1cm are
frequently associated with histologicaly positive lymph node metastasis already at an early tumor stage.
Lymph node metastases seem to occur slightly more frequent in multifocal compared to solitary PTMC’s.
Based on our (Swiss-) experience (no jodine deficiency) with 36% of histologically proven positive lymph
nodes and the recent literature, we advocate routine total thyroidectomy including modified neck dissection as the treatment of choice for papillary thyroid microcarcinomas. However further studies and longterm follow-up are needed to epidemiologically confirm this more radical initial approach.
Objective: It is commonly believed that rotator cuff tears do progress in size over time. Recent reports
suggest that tear progression may not be necessarily true. It was the purpose of this study to review nonoperatively treated isolated supraspinatus tears especially in terms of tear size progression.
Methods: Inclusion criteria were non-operatively treated isolated full-thickness tears of the supraspinatus,
MRI at time of diagnosis available, and patients willing to undergo an additional MRI after more than
2 years after diagnosis. Exclusion criteria were age older than 65 years, contraindications for an MRI,
diseases like Diabetes Mellitus Type 1, Rheumatoid Arthritis, or steroid treatment and a any performed
surgery on the involved shoulder.Twenty-five patients (21 men, 4 women) with an average age of 59
years were reviewed with MRI and clinically based on the Constant score.
Results: The average follow-up was 46 (27-87) months. The Constant score at follow-up (not available at
time of diagnosis) averaged 74 points (relative Constant score 85%). Overall the average tear size did not
change significantly over time (366mm2 at follow-up versus 391mm2 at time of diagnosis, p > 0.05). In
2 patients the tear was not detectable any longer on MRI suggesting that it was healed, in 8 patients the
tear was smaller, in 10 patients it did not change over time and only in 5 patients it progressed. 17 of the
patients considered their shoulder to be good or very good, while 2 considered their shoulder to be bad.
The size or the progression of the tear did not correlate significantly (p >0.05) with the Constant score or
the ability to return to work
Conclusion: Non-operatively treated isolated supraspinatus tears were unchanged, smaller or even healed in 80% of the patients after a follow-up period of more than 4 years. This suggests that supraspinatus
tears do not necessarily progress over time and even have a potential to heal. In conservative treatment,
the size of a supraspinatus tear is not a good predictive factor for the clinical outcome.
5.3
The «long PHILOS®» – a good implant for rare indications
P. Bänninger, M. Dietrich, T. Lattmann, C. Meier, A. Platz (Zürich)
Objective: The evolution of proximal humerus inter locking systems (PHILOS®) providing angular stability
has revolutionized the treatment of proximal humeral fractures in recent years. For fractures extending to
the proximal humeral shaft or as a salvage procedure after failed fixation with another implant, the long
PHILOS® is a suitable alternative. So far, experience with this implant is still scarce. It was the purpose of
this study to collect data such as surgical technique, functional outcome and the rate of complications
when using the long PHILOS®.
Methods: All patients, treated with a long PHILOS® in our institution from 2003 to 2007 entered a specific
database. Demographics, fracture pattern, surgical technique used, functional and radiological outcome,
as well as complications were monitored. Depending on the fracture pattern, either a deltoideo-pectoral
approach with minimally invasive distal plate positioning or an extensive upper arm incision with visualization of the humeral fracture was performed. Shoulder function was evaluated with the Constant-Murley
score.
Results: In the selected time period we used 302 short PHILOS® (3 shaft holes), as well as 13 intermediate length plates (5 shaft holes). Nineteen patients were treated with a long PHILOS®. In that cohort
(mean age 75 yrs. (51 – 88), 11 female) 10 (52%) patients suffered from a proximal humerus fracture
extending to the humeral shaft. Three patients (16%) sustained a pathological fracture. They underwent
resection of the metastasis with subsequent surgical cement filling and osteosynthesis with the long
PHILOS®. Re-osteosynthesis using the longer implant was performed in four patients, one (5%) due to
secondary displacement after fixation of a proximal humeral fracture treated with a short PHILOS® and
three patients (16%) because of a fracture of the plate. A delayed union was cured in two patients (11%)
by stabilizing the fracture with the long implant. Operation took 101 minutes (70 – 190) and was performed usually 4 days (1 – 150) after the trauma. Minimal invasive plate osteosynthesis technique (MIPO)
was performed in 7 (37%) patients. In all procedures involving the long PHILOS® the radial nerve was
identified and treated carefully during the entire operation independent of the technique used. Despite the
complexity of the humeral fracture the functional outcome was good in most cases with a constant score
reaching 74 points (28 – 95) or 79% of the unimpaired shoulder at follow up (9 months (2 - 22)). Neither
intra- nor postoperative complications were documented. Especially no lesions of the radial nerve were
documented. One implant failure with fracturing of the long PHILOS® was found by chance without clinical
evidence 20 months after operation.
Conclusion: The use of the long PHILOS® shows excellent results in terms of functional outcome and
morbidity for a variety of different indications. The increasing use of the MIPO-technique, will reduce large
incisions in future. By handling the radial nerve carefully, lesions can be avoided. Despite the good results
using this implant, very few data on the experience and functional outcome have been published in literature so far.
5.4
Functional results following volar LC T-plate osteosynthesis for unstable distal radius fractures in 293
patients
T. Lattmann, A. Babians, M. Dietrich, A. Platz (Zürich)
Objective: In the past few years, volar plate osteosynthesis of unstable distal radius fractures has become
very popular due to new locking compression implants. We here report functional, subjective and radiological results of 293 patients, all treated with a volar LC T-plate for an unstable distal radius fracture.
Methods: Patients treated with a volar locking compression plate (Synthes® 3.5 mm or 2.4 mm T plate)
between July 2003 and December 2006 entered a specific database and were prospectively followed up
for one year. Range of Motion, grip strength and the subjective patient rated wrist evaluation score (PRWE)
were measured after 6 weeks, three and six months and finally one year after surgery. Furthermore, the
radiological result was monitored using the Lidstrom score.
Results: In the selected time period 293 patients (76% female), with a mean age of 64± 16 years were
operated. According to the AO/Mueller classification, 20 (7%) type A2, 112 (38%) A3, 2 (1%) B1, 8 (3%)
B2, 10 (3%) B3, 52 (18%) C1, 72 (25%) C2 and 17 (6%) C3 fractures were classified. One year follow up
was possible in 223 patients (76%). The PRWE score decreased from 24 points six weeks after surgery to
7 points one year after surgery, representing a very good subjective outcome since the score ranges from
0 to 100 points, where 0 points represents absence of any subjective complaints. Grip strength increased
from 54% after 6 weeks to 91% after one year when compared with the uninjured contralateral wrist. Six
weeks after surgery, flexion and extension were significantly limited when compared with the uninjured
contralateral wrist (flexion 43° vs. 68° ; extension 42° vs. 67° , p< 0.05). After a continuous increase,
flexion and extension reached over 93% of the uninjured wrist (flexion 64° vs. 68° , extension 63° vs. 68°
; p< 0.05) but were still significantly reduced one year after surgery. According to the radiological Lidstrom
score good and excellent results could be achieved in 94% of the cases. Only in two patients a Lidstrom
score of 4 has been measured, both with implant failure. A complication rate of 15% was found in our
series. Fourteen patients were treated for a complex regional pain syndrome, nine patients had a carpal
tunnel syndrome, in six patients an extensor pollicis longus tendon rupture was seen, three patients had a
secondary fracture displacment and in two patients a postoperative haematoma had to be evacuated.
Conclusion: The volar locking compression T-plate is a very good implant for stabilization of unstable distal radius fractures regarding functional, subjective and radiological outcome providing effective fixation
when used for treatment of unstable distal radius fractures. One year after surgery an almost unlimited
functional result can be expected in nearly all cases. Considering that our institution is a formation clinic
the complication rate of 15% is very low when compared with literature, where a rate up to 34% has been
reported.
5.5
Clinical long term results after Kapandji-Sauvé procedure as a salvage procedure at the distal radioulnar
joint
J. Schulze, S. Lang, U. Genewein, H. Troeger (Basel)
Objective: The Karpandji-Sauvé procedure has been developed as a salvage procedure for the treatment
of painful arthrosis of the distal radioulnar joint (DRUJ). This operation is performed as soon as the anatomical reconstruction of the DRUJ is not possible. Our retrospective study aimed to evaluate objective (e.g.
strength, ROM) and subjective measures (pain, satisfaction) after a long term interval and to compare
these with the results obtained by others.
Methods: In this retrospective analysis 45 of 51 patients (20 female, 25 male; mean age: 48 years) were
examined clinically and by X-ray. Reasons to perform Karpandji-Sauvé procedure included posttraumatic
situations (37 distal radius fractures, 4 lower arm fractures, and 2 wrist luxations) and primary DRUJ
arthrosis in 2 cases. Patients with rheumatoid polyarthritis (5 pt.) and Madelung’s deformity (1 pt.) had
been excluded due to co-existing problematic that could bias the analysis. The mean observation interval was 7.2 years (14 months-11 years). The grip strength assessment was performed using JAMAR
dynamometer (TEC, New Jersey, U.S.A) in comparison to the contralateral site. The ROM of the wrist was
evaluated with a goniometer and neutral-null method compared to the preoperative status. The pain was
assessed using a visual-analog scale (VAS; 0=pain free, 10=maximal pain). The results were then summarized using the modified Mayo-Wrist score according to Krimmer. Additionally, we assessed patient
satisfaction and work load in their original profession.
Results: Eighty four percent of our patients reported a significant decrease in pain (p<0.05). The ROM in
terms of pronation (69° vs. 81°) and suppination (62° vs. 82°) improved significantly (p<0.001). The
mean strength related to the contralateral site increased significantly from 34% to 65% (p<0.05). All arthrodeses were completely integrated without any ulna dislocation. The Krimmer score revealed that the
postoperative results were very good in 10 of 45 patients, good in 26 of 45, satisfactory in 6 of 45, and
bad in 3 of 45 patients.
Conclusion: The results of our study show that the preoperative relevant pain was significantly reduced
by this operation leading to a significant improvement in the pronation/suppination of the wrist and an
increase in grip strength followed by a high percentage of patients satisfied. The majority of them went
back to work soon and would undergo this procedure again if necessary. Therefore, to be successful with
Karpandji-Sauvé procedure a very strong patient selection is necessary.
5.6
Behandlung von Mittelhandfrakturen mit dem 2,0mm LCP-system
E. Bodmer, A. Platz, M. Kilgus (Zürich)
Objective: Winkelstabile Implantate stehen mittlerweile auch zur Versorgung von Mittelhandfrakturen zur
Verfügung. Im Sinne einer internen Qualitätskontrolle haben wir unsere Patienten unter besonderer Berücksichtigung der postoperativen Komplikationen nachkontrolliert.
Methods: Retrospektive Studie von 50 Patienten (31 Männer, 19 Frauen, Durchschnittsalter 33 Jahre) mit
55 Mittelhandfrakturen, welche zwischen 2005 und 2007 (24 Monate) mittels einer 2,0mm LCP-Platte
behandelt wurden. Die Patienten wurden klinisch und radiologisch nachkontrolliert. Die subjektive Zufriedenheit wurde mittels PRWE-Score und DASH-Score ermittelt.
Results: Alle Patienten wurden funktionell nachbehandelt und erreichen in den verwendeten Scores gute
Resultate. Komplikationen: Therapiebedürftiger Infekt oder Hämatom: 0; fehlende Frakturheilung: 0; sekundäre Frakturdislokation: 1; vorübergehende Neuropraxie dorsaler Hautnerven: 17; iatrogene Nervendurchtrennung: 1; Tenosynovitis der Strecksehnen/eingeschränkte Grundgliedbeweglichkeit: 35; Beugesehnenirritationen-/rupturen: 0; CRPS: 0
Conclusion: Die Verwendung winkelstabiler Implantate zur Versorgung von Mittelhandfrakturen hat sich
bewährt. Wir werden auch künftig das LCP-System bei sehr proximal und distal gelegenen Schaftfrakturen, diaphysären Spiral- und Mehrfragmentfrakturen, intraartikulären Basisfrakturen sowie beim alten
Patienten mit osteoporotischem Knochen verwenden. Dadurch sind funktionell gute Resultate mit einer
niedrigen Komplikationsrate zu erreichen.
5.7
Prospective evaluation of snow sport accidents
A.P. Businger1, C. Schrofer2, C. Sommer2 (1Basel, 2Chur)
Objective: Wintersport accidents are the third common accidents in Switzerland with a major socio-economical impact. About three-quarter of all wintersport accidents are due to skiing and snowboarding.
Recent years have shown a revolution in skiing by introduction of carving. Furthermore snowboarding has
established itself in the market. The study aimed to investigate the characteristics of skiing and snowboarding accidents including external factors, such as visibility and piste conditions, equipment and personal
skills.
Methods: As part of a prospective study at a trauma center in eastern Switzerland 339 (of 854 injured
persons during wintersport accidents) injured snowboarders were asked during the winter 2006/2007
about 39 differenct criteria according to accident, person, and circumstances and the data were collected
in a database.
Results: The mean age (standard deviation) was 22 years (7), and 183 of the 339 subjects (53%) were
male. About 50% of the injured snowboarders are beginners. 17% of them are injured during there first
day snowboarding. Most of snowboarding accidents are due to a fall, only 13% of snowboarding accidents are collisions. 62% of all injuries are due to direct impact on the ground. Injuries to the lower extremities account for 29%. The supporting leg is affected in 88% of all injuries of the lower extremity. Wrist,
knee and shoulder are the most frequently injured body parts. The risk for an injury is mainly influenced by
bad weather conditions. The use of protectors reduce the risk for a serious injury up to 40%. Surprisingly
only 44% of all participants indicated that they know the FIS rules of conduct. Alcohol and drugs are only
involved in 4.9% of all accidents in this group.
21
Conclusion: External conditions have a major impact on the risk and the injury pattern. The average knowledge about rules of conduct in these participants is mediocre, and a serious lack of knowledge exists
especially in prevention. The use of protectors has a positive effect. The support of up-to-date protectors
and training of falling techniques could reduce the numbers and the seriousness of injuries.
5.8
Incidence and analysis of in-hospital falls in a large training hospital: has a fall-prevention instruction an
impact on the severity of injuries?
A. Platz, M. Dietrich, U. Can, M. Bana Signer, U. Metzger (Zürich)
Objective: In elderly patients, falls in hospitals are unwanted events. Only few information in the literature
concerning incidence and severity of patients that fell is available during hospitalization. In 2005 a general instruction on fall-prevention was established in our large training hospital. The goal of this protocol
was to recognize the patients at risk for falls and also to reduce the total number of in-hospital falls or at
least to reduced the number of severe injuries.
Methods: In 2005 in our hospital a general instruction for fall prevention was implemented. Goal of this
instruction was to document risk-factors and planning of prevention. All falls of patients in the hospital
were documented with a special protcol, either by doctors or nurses. All in-hospital falls of 2005 and 2006
were analyzed. Of special interest were the number of fractures that occurred during an in-hospital fall.
Also risk-factors, circumstances of the fall, measures, prevention and injuries were documented
Results: In 2005 469 of total 14’181 patients (3.3 %) suffered an in-hospital fall, whereas in 2006 we
also registered 469 falls of total 14’684 patients (3.2%). Fractures as severe consequence of a fall had
25 of 469 patients (5.3 %) in 2005 and 18 of 469 (3.3 %) in 2006. Regarding open wounds we saw in
2005 23 patients (4.9%) that needed an operative wound closure and in 2006 27 patients (5.8%). The
most important risk-factors were patients with reduced mobility, impaired cognitive function, side effects
of drugs and wrong footwear.
Conclusion: Although the total number of in-hospital falls was not reduced, the fracture-rate could be significantly reduced from 25 fractures in 2005 to 18 fractures in 2006. The fall prevention protocol has
a positive impact on reducing severe injuries because nurses and doctors paid more attention to the
problem and the underlying causes. We are convinced that in the future a fall-prevention program is mandatory for hospitalized geriatric patients and will reduce the number and the severity of falls in this patient
population.
5.9
Metallentfernung durch Stichinzisionen – Entlastung für Patient und Spital
D.A. Müller, K. Niederhauser, D. Heim (Frutigen)
Objective: Die Indikation zur Metallentfernung wird heutzutage kontrovers diskutiert. Metallentfernungen
sollten deshalb eine möglichst geringe Morbidität und eine minimale Komplikationsrate aufweisen. Dies
kann mit Implantatentfernungen durch Stichincisionen erreicht werden, womit eine grosszügige Freilegung des Implantates, wie sie früher üblicherweise praktiziert wurde, entfällt.
Methods: Regionalanästhesie, Blutsperre, Implantatlokalisation und -Markierung unter BV-Kontrolle, Stichinzision zur Schrauben bzw. Drahtentfernung, Lockerung und Ausschlagen der Platte durch die distale
oder proximale Inzision mit einem Einzinkhaken oder mit einem speziellen Plattenextraktor. Redondrainage im Plattenbett für einige Stunden bei Patienten mit Bettenbenutzung, easy flow-Drainage bei Patienten
ohne Bettenbenutzung. Durch die oben genannte Methode ist es möglich die Operation unter tageschirurgischen Bedingungen ohne Hospitalisation über Nacht durchzuführen. Einzige Ausnahme dabei bildet
die Metallentfernung am Femurschaft.
Results: Von 01.01.2000 bis 31.12.2007 wurden in dieser Technik 161 Metallentfernungen mit einer
durchschnittlichen Operationsdauer von 25 Minuten durchgeführt. Lokalisationen und Häufigkeit: Malleolus lateralis 79, Tibiaschaft 38, Malleolus medialis 14, Vorderarmschaft 10, Femurschaft 5, Patella 5,
Olecranon 4, Tibia proximal 3, Clavicula 2, Os metatarsale 1. Im gesamten Patientengut traten keine neurologischen oder trophischen postoperativen Komplikationen auf. Einzig bei einem Patienten mit einer
Tibiaplattenentfernung kam es nach einer frühzeitigen Redonentfernung beim Umlagern des Patienten zu
einem Hämatom und 10 Tage später zu einer Staphylococcus aureus-Infektion, welche aber nach offener
Revision und resistenzgerechter antibiotischer Therapie folgenlos zur Ausheilung kam.
Conclusion: Mit Ausnahme der DHS am proximalen Femur kann an fast allen Körperlokalisationen eine
solch minimal invasive Metallentfernung mit einer sehr geringen Morbidität und Komplikationsrate vorgenommen werden. Die nachfolgende Arbeitsunfähigkeit ist minimal und die oben genannte Technik bietet
dem Patienten deutlich mehr postoperativen Komfort. Durch vermehrten Einsatz von i.v.-Block-Anästhesien auch am Unterschenkel, entfällt eine sonst übliche Spinalanästhesie. Dies ermöglicht eine sofortige
Spitalentlassung des operierten Patienten, wodurch in ausgewählten Fällen in Zukunft die Patientenbelastung bei einer Metallentfernung am Malleolus zusätzlich gesenkt werden kann.
Visceral Surgery
06
6.1
Natural Orifice Translumenal Endoscopic Surgery (NOTES) for Roux-en-Y gastric bypass: an experimental surgical study in human cadavers
M. Hagen1, F. Pugin1, O.J. Wagner2, P. Swain3, P. Bucher1, N.C. Buchs1, J.H. Fasel1, Ph. Morel1 (1Genève,
2
Bern, 3London/UK)
Objective: Advantages of a NOTES or NOTES hybrid approach to Roux-en-Y gastric bypass (RYGBP) might
22
include: easier access to the peritoneal cavity, substantial reduction in number of ports and port related
complications, improved cosmesis and others. NOTES was initially concieved as a procedure for relatively minor intraperitoneal operations. The most common NOTES procedure currently is cholecystectomy
which is of moderate complexity. RYGBP is a difficult surgical procedure of advanced level. The technical
feasibility of a NOTES-RYGBP and limitations of available flexible and rigid instrumentation for such a procedure is unknown.
Methods: NOTES hybrid RYGB was performed in 6 human cadavers (frozen or preserved) using a combination of flexible and rigid instruments. Pouch creation was achieved by needle knife dissection of a
retrogastric window using a flexible gastroscope introduced transvaginally. Articulated linear staplers
were placed through a transumbilical port to transect the stomach. Measurements of the bilary and alimenary limbs were accomplished with flexible and rigid graspers or intralumenally. A 21 mm anvil was
introduced through a needle-knife incision into the small intestine and connected to the flexible shaft of
a flexible transesophageal stapler to form a gastrojejunostomy. A linear stapler was used for the jejunojejunal anastomosis.
Results: It was feasible to perform bypass surgery in all cadavers. Dissection and pouch creation was
easier than expected using flexible instruments to form the pouch. Ordinary rigid instruments (graspers
and staplers) were too short for some transvaginal or transrectal manipulations. Anvil manipulation
and docking was difficult using flexible instruments. Combinations of flexible and rigid visualization and
manipulation were especially helpful for pouch creation and stapler manipulation. Transabdominal port
access number was reduced from 5-7 to 1-3 with 1-2 translumenal access ports.
Conclusion: Roux-en-Y bypass surgery is technically feasible in human cadavers using a NOTES hybrid
approach. Port numbers can be reduced. A combination of flexible with rigid endoscopic techniques devices offers specific advantages for components of this type of surgery. Changes in instrument design are
required to improve complex hybrid endosurgical procedures.
6.2
Laparoscopic Sleeve-Gastrectomy (LSG) in the treatment of morbid obesity: early results
B. Uglioni, B. Kern, T. Peters, C. Christoffel, M. von Flüe, R. Peterli (Basel)
Objective: LSG is the restrictive part of bilio-pancreatic diversion duodenal switch (BPD) that has recently
been used as an isolated operation in a staged therapy concept. We investigated early results of LSG in
a prospective pilot study.
Methods: Between 5/04 and 01/07 LSG was performed on 53 pts, 25 times after failed gastric banding,
73% were female, mean age was 43 (21-65) years, mean initial BMI 46 (35-58) kg/m2. Mean follow-up
time was 20 (12-35) months, the rate was 100%. Primary outcome measures were early morbidity, initial
weight loss and BAROS-Score.
Results: Mean operative time was 117 (70-200) min. for primary LSG and 146 (100-240) min. for LSG
after gastric banding (p=0.01). No intraoperative complications were observed, no conversions. Early
morbidity was 15% (dysphagia 2x including kinking of the stomach, portal vein thrombosis 1x, nonsurgical 4x), and mortality was null. Up to date laparoscopic BPD had to be performed twice after insufficient weight loss following LSG. Mean BMI loss 12 months postop. was 11 kg/m2 following LSG,
corresponding to an excessive BMI loss of 68% (n=47) and 59% (n=18) 24 months postop. respectively.
Co-morbidities were cured or improved in 36%. The BAROS Score 1 year postop. was excellent to good
in 95% of patients.
Conclusion: LSG is a safe initial bariatric procedure in a staged concept and has the potential to be sufficient as definitive operation in the majority of patients. Weight loss after LSG seems to be good, but
until long-term results exist it is still an experimental bariatric procedure and should only be performed
in controlled trials.
6.3
Vagal Block for Obesity Control (VBLOC™) – preliminary results of an ongoing, open-label, phase I clinical study from a single center
D.M. Frey1, C.T. Viehl1, R. Stöckli1, R.R. Wilson2, D. Oertli1, U. Keller1 (1Basel, 2St. Paul/US)
Objective: Obesity is a global medical problem with increasing prevalence, associated with a high morbidity and mortality. The currently available treatment options do not meet the needs of all obese patients.
Activation and up-regulation of the efferent and afferent fibers of the intra-abdominal vagal nerve trunks is
a pivotal physiological mechanism for food ingestion, mechanical processing, enzymatic digestion and
calorie absorption. A novel medical device (Maestro™ System) has been designed to take therapeutic benefit from these physiological principles by reversibly and controllably down-regulating/blocking both the
anterior and posterior intra-abdominal vagal trunk in order to: (1) reduce food intake by reducing gastric
volume; (2) initiate early and prolonged satiation by delaying gastric emptying; and (3) decrease calorie
absorption by down-regulating pancreatic exocrine secretion and nutrient assimilation. The objective of
the present investigation is to evaluate the safety, efficacy and treatment algorithms of the Maestro™ system causing weight loss in obese subjects.
Methods: The study was designed as an open-label, multi-center, prospective clinical trial with four participating University Hospitals in Mexico City, Adelaide, Trondheim and Basel. The vagal blocking system
(Maestro™, EnteroMedics Inc., St. Paul, MN, USA) was laparoscopically implanted after patient’s informed
consent was obtained. Two weeks later, vagal blocking was initiated using optimized therapy algorithms
based on data from an earlier feasibility trial. Subjects have been followed to 6 and 12 months respectively
for excess weight loss (EWL) and for adverse events with physical and lab exams.
Results: Nine subjects (median BMI: 37.5 kg/m2 ) were implanted at the University Hospital of Basel. The
average weight reduction after 6 months was 7.25 kg (range 1 – 17kg). Appetite (as measured by a visual analogue scale, 1 -100 mm) was reduced from 69 to 41 mm. Waist circumference was reduced by 9
cm (range 0 -14 cm).There were no serious adverse events associated with the device, although one subject was hospitalized for two days because of peripheral lung embolism. One subject left the study after
6 months because of weight loss she considered insufficient and unsatisfacory suppression of appetite.
The remaining subjects demonstrated ongoing weight loss up to the last follow-up (December 2007).
Conclusion: These preliminary results of a novel medical device to reversibly and controllably block the
intra-abdominal vagal trunk suggest the safety and efficacy of the Maestro™ system in the treatment of
morbidly obese subjects. Patients will continue in a long-term follow-up protocol.
6.4
Long-term quality of life after bariatric surgery – a comparative study of banding vs. bypass
C. Wenger, M.K. Müller, S. Wildi, M. Schiesser, P.-A. Clavien, M. Weber (Zürich)
Objective: Abstract Laparoscopic gastric banding and Roux-en-Y gastric bypass are widely used for the
treatment of morbid obesity. Laparoscopic Roux-en-Y gastric bypass provides better control of weight
and reduction of co-morbidities compared to laparoscopic banding. The impact of these two procedures
on health–related quality of life has not been analyzed in a comparative study. Aims To define whether
laparoscopic gastric banding or laparoscopic Roux-en-Y gastric bypass have a different impact on quality
of life in patients with surgically treated morbid obesity.
Methods: A matched-pair analysis of a large prospectively collected database, including 1062 bariatric
procedures operated at our institution between 1995 and 2007, was performed. 52 consecutive patients with laparoscopic gastric bypass were randomly matched to 52 patients with laparoscopic gastric
banding according to age, BMI and gender. Quality of life was assessed using two standardized questionnaires (SF-36 & Moorehead-Ardelt) and a center specific questionnaire.
Results: Mean preoperative BMI was 45.7 kg/m2 for the bypass patients and 45.3 kg/m2 for the banding
patients. Mean BMI after 4 years follow up was 30.4 kg/m2 and 33.1 kg/m2 (p=0.036), this corresponds
to a BMI loss of 33.7% and 25.2% (p=0.002), respectively. For the SF 36 questionnaire gastric bypass
patients yielded a mean total score of 613 versus 607 points in the gastric banding group (p= 0.543),
which is comparable to the normal population in Europe. In the Moorhead-Ardelt questionnaire the gastric
bypass patients scored a mean total of 1.35 points and the gastric banding patients 1.28 points (p=
0.747). 97% of patients with a gastric bypass and 83% of patients with a gastric banding were satisfied
with the result of the operation (p=0.145). 89% in the bypass group and 95% in the banding group (p=
0.419) would undergo the same operation again.
Conclusion: Patients after laparoscopic gastric bypass and laparoscopic gastric banding have a high
level of satisfaction four years after the operation and have similar quality of life scores compared to the
normal population. Quality of life indexes were not different between the two procedures and were independent of weight loss in successfully operated patients.
6.5
Total robotic Roux-en-Y gastric bypass with the da Vinci® surgical system
Ph. Morel, F. Pugin, I. Inan, G. Chassot, M. Hagen (Genève)
Objective: The gold standard for Roux-en-Y gastric bypass (RYGBP) is currently a laparoscopic approach
with stapled anastomoses. This approach is feasible, but associated with a high complication-rate. Few
centers perform robotic-assisted RYGBP with stapled entero-entero-anastomosis in order to avoid re-arrangement of the robot during the procedure. We hypothesize that total robotic RYGBP 1.) may be conducted entirely without changing the position of the robot 2.) may result in fewer complications.
Methods: We developed a technique for total robotic RYGBP with robotically-sewn gastro-entero and entero-entero-anastomosis without re-arrangement of the robot during the procedure. We evaluated prospectively the results concerning complications (regarding anastomoses and overall), duration of suturing of
anastomoses and complete procedure.
Results: Until now, we have performed 23 total robotic RYGBPs. Duration of operation ranged from 210 to
410 (Median: 290) minutes with a rapid learning curve. Duration of anastomoses ranged from 30 to 75
(Median: 45) minutes. Robotic docking was achieved in a range from 10 to 20 (Median: 12) minutes. All
procedures were finished with the robot in it`s initial position and all areas of the operating field could be
reached with the robotic instrumentation. We have not observed any complications of anastomoses.
Conclusion: The data support the conclusion that total robotic RYGBP is feasible without re-arrangement
of the robot during the procedure. Robotically sewn gastro-entero and entero-entero-anastomoses seem
to be superior when compared to stapled anastomoses.
6.6
Reversibility of esophageal dysmotilities after conversion from gastric band to gastric bypass
J. Borovicka1, B. van der Weg1, B. Schultes1, C. Grübel1, M. Marty1, P. Kuenzler1, D. Pohl1, M. Fried1,
C. Meyenberger1, R. Tutuian2, M. Thurnheer1 (1St. Gallen, 2Zürich)
Objective: Recent studies report on esophageal motility disorders induced by gastric banding, on occasions severe enough to mimic pseudoachalasia. To datethere are insufficient data whether these changes
are reversible or not. AIM: Evaluate changes in esophageal symptoms, peristalsis, bolus transit and clearance before and 3 months after conversion from gastric banding to gastric bypass.
Methods: Patients scheduled for conversions from gastric banding to gastric bypass were evaluated
before and 3 months after conversions. Clinical assessment included 7-point Likert scale rating of dysphagia, heartburn, regurgitation and chest pain. Esophageal persistalsis and bolus transit were assessed
using combined impedance-manometry. Esophageal emptying was assessed using a modified timed
barium swallow (esophageal barium column measured on chest X-rays 30, 60 and 180 seconds after
ingestion of oral contrast).
Results: Twenty-four patients (20 F, mean age 45, range 28-61 years) completed pre- and post-operative
(average 98, range 63-186 days) evaluations. Conversion from gastric banding to bypass improved esophageal symptoms, esophageal bolus transit (impedance) and clearance (timed barium swallow) while
there was a trend in improved esophageal peristalsis (manometry). Pre- and post-conversion parameters
are summarized in table1.
Conclusion: Conversion from gastric band to gastric bypass improves esophageal symptoms and function. Abnormal motility caused by gastric banding may persist in some patients after to gastric bypass.
However few of these patients are symptomatic and have abnormal bolus transit.
6.7
Innere Hernien nach laparoskopischem Magenbypass
R. Fahrner, T. Köstler, O. Schöb (Schlieren)
Objective: Der laparoskopische Magenbypass hat in den letzten Jahren aufgrund geringer postoperativer
Morbidität und gutem Gewichtsverlust einen immer grösseren Stellenwert in der bariatrischen Chirurgie
erlangt. Die innere Hernie zählt zu den technischen Spätkomplikationen nach Roux-Y-Magenbypass, bei
der sich Darmschlingen in einem Mesodefekt torquieren. Es handelt sich dabei um eine der schwerwiegendsten Komplikationen.
Methods: In dieser retrospektiven klinischen Untersuchung wurden die postoperativen Verläufe von 223
Patienten mit laparoskopischem distalem Magenbypass und antekolischer Roux-Y-Schlinge in einem Untersuchungszeitraum von Januar 2000 bis August 2007 untersucht. Es erfolgte kein routinemässiger Verschluss der Bruchlücken im Rahmen der Primäroperationen. Erfasst wurden der Zeitpunkt, die Häufigkeit
einer inneren Hernie, sowie die klinischen Zeichen. Weiter wurde der Einfluss des Gewichtsverlustes auf
das Auftreten dieser Komplikation analysiert.
Results: Bei den 223 Patienten handelte es sich um 169 Frauen (76%) und 54 Männer (24%), mit einem
Durchschnittsalter von 41 Jahren (19 – 73 Jahre), und einem durchschnittlichen Verlauf von 451 Tagen
(7 – 2520 Tage). In 20 Fällen (9%) wurde nach einem Intervall von 678 Tagen (154 – 1596 Tage) ein
Verschluss der Mesenterialdefekte durchgeführt. Patienten mit innerer Hernie wiesen dabei eine grössere
BMI-Differenz auf als Patienten ohne Hernie (15,1 vs. 11,7 kg/m2). 6 Patienten präsentierten sich mit
plötzlich und vor weniger als 24 Stunden aufgetretenen Abdominalschmerzen in der Klinik. Bei der Untersuchung zeigte sich eine Diskrepanz zwischen stärkster subjektiver Abdominalschmerzen, und klinisch
vorliegender geringer abdomineller Druckdolenz ohne Zeichen eines Peritonismus. Weiter bestand bei
den Patienten ein nahezu unauffälliges Labor (Leukozyten 10,75 G/l und CRP 6 mg/l). Bei 5 Patienten
erfolgte die weitere Diagnostik mittels Computertomographie, hier liess sich bei 3 Patienten direkt eine
Hernie nachweisen, bei 2 Patienten lediglich eine Passagestörung, so dass eine notfallmässig Operationen vorgenommen wurde. In 4 Fällen handelte es sich um eine Petersen-Hernie, in 2 Fällen war es
zu einer Hernierung im Bereich des Meso-Meso-Schlitzes gekommen. Eine weitere Patientin war nach
528 Tagen verstorben, bei der sich in der Sektion eine innere Hernie nachweisen liess. Auch hier bestand
klinisch lediglich eine Druckdolenz im Epigastrium, ohne peritonitische Zeichen.
Conclusion: Innere Hernien sind als Spätkomplikation nach laparoskopischem distalem Roux-Y-Magenbypass zu nennen. Insbesondere Patienten mit grossem und schnellem Gewichtsverlust scheinen ein
erhöhtes Risiko für die Entwicklung einer inneren Hernie zu haben. Sie sind zwar selten, jedoch als potentiell lebensgefährlich einzustufen, daher ist eine frühzeitige Diagnose und Therapie anzustreben, um
schwerwiegende Folgen zu vermeiden. Da sie häufig mit subjektiv starker Abdominalschmerzen, ohne
Peritonismus und blandem Labor einhergehen, ist eine sichere Identifikation der Patienten schwierig.
Anhand unserer bisherigen Erfahrung sollte eine aggressive Abklärung mit Computertomographie bei
unklaren Abdominalbeschwerden nach Magenbypass und eine frühe diagnostische und therapeutische
Laparoskopie vorgenommen werden.
6.8
Deficiencies before and after Laparoscopic Sleeve-Gastrectomy (LSG) and Laparoscopic Roux-Y-GastricBypass (LRYGB)
S. Gehrer, B. Kern, T. Peters, C. Christoffel, M. von Flüe, R. Peterli (Basel)
Objective: Deficiencies of micronutrients after bariatric operations are frequent despite routine supplementation. Main outcome measures were pre- and postoperative frequency of deficiencies and success
rate of their treatment.
Methods: Between 5/2004 and 12/2006 136 patients (m:f = 0.4) with an average BMI of 45 (26-58)
kg/m2 and age of 53 (21-66) years were prospectively analyzed. In 86 patients LRYGB, and in 50 LSG
was performed. Patients were examined before surgery and 3, 6, 12, 24, and 36 months postoperatively
using a standard protocol including laboratory tests. The mean follow-up-time was 13.2 (3-40) months,
the rate was 100%.
Results: Prior to surgery, 34% of the patients had at least one deficiency: 14% had zinc deficiency, 8% had
elevated PTH and 6% showed low levels of albumin. Postoperatively we found the following deficiencies
(in %):
Vit. B1 Vit. B6 Vit. B12 Vit. D3 Ca Hyperpara Folic acid Ferritin Zn Albumin LSG (n=50)
0
0
16 28 0
14 20 18 30 4
LRYGB P value LSG Successfull (n=86)
Therapy (in %) Therapy (in %)
0 0 42 0.001 80 42 (0.08) 0 28 0.05 100 8
0.04 100 22 n.s 100 31 n.s 88 7
n.s LRYGB Successfull
89
100
91
100
33 (75 i.v.)
100
Conclusion: Preoperatively, 34% of morbidly obese patients already had a deficiency. Frequent deficiencies after LSG were zinc, vit. D3, folic acid, and ferritin; after LRYGB: vit. B12, vit. D3, zinc, and hyperparathyroidism. No vit. B1- or B6-deficiency was found. Calcium levels were normal in all patients, thus PTH and
vit. D3 are more sensitive markers for early detection of disorders of bone metabolism. Iron-anaemia in
LRYGB-patients is best treated by iv-therapy.
23
6.9
Distal Roux-en-Y gastric bypass for the treatment of morbid obesity
J.M. Heinicke, B. Schnüriger, Y.M. Borbely, P. Müller, D. Candinas (Bern)
Objective: We present mid-term results of a pilot study using a distal, only moderately restrictive Roux-en-Y
gastric bypass (dRYGB) in 61 consecutive patients suffering from morbid obesity (BMI>40 kg/m2).
Methods: The almost purely restrictive mechanism of classical gastric bypass was avoided by forming
a proximal gastric pouch of approximately 60 ml on the lesser curvature and by using a 25mm circular
stapler for the gastrojejunostomy. Malabsorption was achieved by constructing a common channel of
110 to 150 cm. The biliopancreatic limb length was 100cm.
Results: 26 open and later on 35 laparoscopic interventions have been performed in 40 females and 21
males with a median age of 41 years and a median BMI of 50 kg/m2. 5 patients had removal of a gastric
banding at the same operation. Median postoperative hospitalisation time was 10 days. No severe intraoperative complications have been observed and no anastomotic leakage was noted in the postoperative
period. 4 patients needed balloon dilation of an anastomotic stricture. Besides these 4 patients no others
have been reporting vomiting or marked restriction in food intake so far. 15 patients were easily treated by
pancretic enzyme supplementation for intermittent diarrhea or steatorrhea. Two marginal ulcers occurred
at the gastrojejunostomy. The 51 patients with a follow-up time of over 12 months (median 24 months)
showed an overall median BMI-reduction of 17 to an actual median BMI of 31.6 kg/m2, corresponding
to an Excess-BMI-Loss (EBL) of 74%. Obesity-related comorbid conditions were significantly reduced or
cured.
Conclusion: dRYGB shows excellent results with marked reduction of weight and comorbid conditions.
This new technique has proved to be feasible and safe. Avoiding massive restrictive measures allows a
more physiological food intake and a continuous increase in quality of life. Furthermore the risk of protein
malabsorption is greatly reduced compared to biliopancreatic diversion.
Research
07
7.1
Intra-individual comparison of human ankle and knee chondrocytes in vitro: relevance for talar cartilage
repair
C. Candrian1, E. Bonacina2, J. Frueh2, S. Dickinson3, D. Wirz2, M. Heberer2, I. Martin2, A. Barbero2
(1Bruderholz, 2Basel, 3Southmead/UK)
Objective: Cell-based cartilage repair techniques for the treatment of chondral lesions of the talus generally use knee chondrocytes (KC). The use of talar chondrocytes (TC) instead of KC would be supported
by the potential advantage of having superior biosynthetic activity and of deriving from a joint with greater
capacity for repair in response to damage. However, TC or KC would need to be isolated from their own
microenvironment and expanded in vitro, which is typically associated with cell dedifferentiation. We thus
aimed at comparing TC and KC derived from the same donor with respect to: (i) proliferation rate, (ii)
post-expansion biosynthetic activity and capacity to generate cartilaginous tissues and (iii) response to a
catabolic factor normally present in injuried joints, namely IL-1b.
Methods: TC and KC were isolated from biopsies of the femoral condyle or of the talus of 10 individuals
and expanded in monolayer for 2 passages. Expanded cells were then cultured as pellets for 3 or 14
days, or in porous hyaluronan meshes (Hyaff®-11, FAB, IT) for 14 or 28 days. The generated tissues were
assessed biochemically [glycosaminoglycans (GAG), DNA, collagen types I and II], histologically (Safranin-O), by real time RT-PCR (collagen types I and II) and mechanically [Equilibrium modulus (EEQ) and
the Pulsatile dynamic modulus (EPD)]. The proteoglycan and collagen synthesis of the cell pellets were
measured by assessing the incorporation of [35S]SO4 and [3H]proline for a period of 24h following or
not exposure to IL-1ß.
Results: TC and KC displayed similar proliferation rates. Following 14 days of pellet culture TC and KC
expressed similar amounts of type I and II collagen mRNA and produced tissues with comparable quality
and amount of GAG and collagens. Proteoglycan and collagen synthesis increased between 3 and 14
days of pellet culture to a similar extent for TC (6.4-fold and 1.5-fold respectively) and KC (7.8-fold and
1.2-fold respectively). The drop in proteoglycan and collagen synthesis following exposure to IL-1ß was
similar between TC and KC. Following 14 days of culture in Hyaff®-11, TC and KC generated tissue with
similar quality and amounts of GAG and collagens. The increase in the contents of these macromolecules
from 2 to 4 weeks culture was larger in tissues generated by KC, resulting in significantly higher final GAG
and type II collagen contents (1.6- and 2.2-fold respectively). EEQ and Edyn, significantly increased between
2 and 4 weeks of culture to a similar extent in tissues generated by TC and KC.
Conclusion: We demonstrated that the superior synthetic activity of TC as compared to KC is lost when
chondrocytes, isolated from their original matrices, are de-differentiated and subsequently induced to redifferentiate, suggesting a critical role of the tissue environment in determining the properties of KC or
TC. This study reinforces that KC could represent a suitable cell source for the repair of cartilage lesions
of talus.
7.2
Radiation-induced expression of fibrogenic cytokines in the anal sphincter of patients with rectal cancer
P. Gervaz1, Ph. Morel1, M. Vozenins-Brotons2 (1Genève, 2Villejuif/FR)
Objective: Pelvic irradiation negatively impacts on anorectal function, but the molecular mechanisms
responsible for radiation-induced damage to the anal sphincter remain unclear. The aim of this study
was to assess Transforming Growth Factor-beta1 (TGF-ß1) and Connective Tissue Growth Factor (CTGF)
expression in the internal and external sphincter of rectal cancer patients who underwent neoadjuvant
24
radiation therapy and abdomino-perineal resection (APR).
Methods: Operative specimen from sixteen irradiated (Group 1) and four non-irradiated (Group 2) patients were analyzed. Tissues samples of the internal sphincter (IS), external sphincter (ES), and rectus
abdominis muscle [RAM-Control] were collected at the time of surgery, six weeks after radiation therapy
(total dose 50.4 Gy) and maintained at –80°C until use. Samples were crushed to powder in liquid nitrogen and total mRNAs were isolated by Chomzynski method. CTGF and TGF-ß1 mRNA expression were
assessed by real time reverse transcription-polymerase chain reaction (RT-PCR).
Results: In Group 1, median expression of CTGF mRNA was markedly increased in the IS by comparison with the ES and the RAM (39.8 vs. 9.2 vs. 1.0, Friedman test, p=0.003). In Group 2, CTGF mRNA
expression was absent or very low in all 4 cases. In Group 1, overexpression of TGF-ß1 mRNA was also
detected in the IS, as well as the ES, but not in the RAM (26.4 vs. 14.2 vs. 1.0, Friedman test, p=0.01).
Finally, immunohistochemical staining revealed that CTGF protein expression was predominantly located
in the myo-fibroblasts and endothelial cells of the IS.
Conclusion: The data presented here demonstrate overexpression of fibrogenic cytokines produced by
myo-fibroblasts in the anal canal of patients irradiated for rectal cancer. CTGF and TGF-ß1 mRNA expression predominate in the internal sphincter, which appears as the most radiosensitive structure of the anal
canal. However, the induction of both fibrogenic cytokines in the ES suggests a significant and unexpected
contribution of the striated muscle to radiation-induced remodeling. Those molecular alterations are likely
to be responsible for fibrosis in the anal canal and subsequent poor functional results of low anterior
resection.
7.3
Safety of controlled VEGF expression in a model of chronic hind limb ischemia
T. Wolff, P. Fueglistaler, H. Misteli, E. Mujagic, R. Gianni-Barrera, L. Gürke, M. Heberer, A. Banfi (Basel)
Objective: Therapeutic angiogenesis is a promising strategy for the treatment of end stage peripheral
artery or coronary artery disease. Delivering vascular endothelial growth factor (VEGF) by intramuscular
injection of in vitro engineered myoblasts might prove superior to conventional gene delivery systems
because it leads to prolonged VEGF-expression, which has been shown to be necessary for the formation
of stable vessels. However, high levels of VEGF induce uncontrolled vessel growth and we have shown
that even small numbers of myoblasts secreting high levels of VEGF are sufficient to cause vascular tumors. We have developed a FACS-based method to rapidly purify myoblasts expressing specific levels of
VEGF. The present study aims to determine whether VEGF delivery by FACS-sorted myoblasts is safe when
applied in ischemic tissue, where endogenous angiogenic stimuli are activated and secondarily, if it can
lead to improved perfusion.
Methods: Chronic ischemia in the hind limb of nude rats was induced by bilateral ligation of the femoral
artery. One week later, VEGF-engineered myoblasts were injected into the adductor and quadriceps muscles (12 injections of 1 Mio cells per leg). Six groups were compared: FACS-purified myoblasts producing
50-60ng of VEGF/Mio cells/day, unsorted myoblasts with very heterogeneous VEGF levels but producing
an average of also 50-60ng VEGF/Mio cells/day, myoblasts from a clone homogeneously expressing
60ng/Mio cells/day, negative control cells, vehicle alone and non-ligated animals. In 82 rats (n=10-15 /
group) blood flow in individual leg muscles was measured by injection of radioactive microspheres in the
aortic arch four weeks after injection. Histological assessment (HE and immunostaining for PECAM, SMA,
NG-2) after 1 (n=22) and 3 months (n=20) was used to quantify angiogenesis, judge the morphology of
the induced vessels and evaluate the appearance of aberrant vessels or vascular tumors.
Results: Bilateral ligation of the femoral artery led to a reduction of maximum blood flow in the gastrocnemius muscle from 176 ml/min/100g in the non-ligated animals to 39 ml/min/100g at 1week after ligation. Four weeks after treatment with vehicle or control cells, maximum flow was still reduced to 73 and 80
ml/min/100g (p<0.01). Treatment with FACS-purified, clonal and polyclonal cells led to blood flows of 87,
83 and 76 ml/min/100g respectively (p=n.s.). No vascular tumors at the site of myoblast injection was
observed on macroscopic examination. The histological analysis of the vascular morphology is being
completed.
Conclusion: We show that femoral artery ligation in the nude rat leads to a chronic blood flow reduction
and thus serves as a model to investigate the safety and efficacy of strategies for therapeutic angiogenesis. Our results suggest that intramuscular injection of FACS-purified myoblasts secreting specific levels
of VEGF is safe in chronically ischemic muscle, as it completely avoids vascular tumor growth. The failure
to improve blood flow distal to the site of myoblast injection is most likely due to an insufficient number of
cells injected, as preliminary observations suggest that the survival rate of injected myoblasts is low. The
appropriate number of cells to be injected to achieve efficacy will need to be determined before planning
clinical trials with cell-based VEGF delivery for therapeutic angiogenesis.
7.4
C-jun N terminal kinase inhibition does not decrease lung injury after ischemia-reperfusion injury in
rodents
C. Cheng, T. Krueger, F. Mithieux, I. Letovanec, H.B. Ris, J.D. Aubert (Lausanne)
Objective: Ischemia/reperfusion injury has been identified as the main cause of primary graft dysfunction
in the first 72 hours after lung transplantation. It has been demonstrated that c-jun N terminal kinase (JNK)
activation plays a critical role in the pathogenesis of ischemia/reperfusion induced injury. We hypothesize
that JNK inhibition may reduce ischemia/reperfusion injury after lung transplantation.
Methods: 12 Fischer rats underwent clamping of the left pulmonary artery (PA) via left thoracotomy for
90 min followed by restoration of the pulmonary circulation for 160 min, with (n=6) and without (n=6) i.v.
administration of a JNK inhibitor (XG-102, Xygen, Lausanne). At this time point, both lungs were harvested
and underwent broncho-alveolar lavage (BAL) followed by histological assessment and intravascular
neutrophil count in the lung assessed on H&E and MPO- stained slides on 10 successive high power fields
(HPF). Controls underwent either thoracotomy with dissection of the hilum but without PA clamping (n=6)
or anaesthesia without thoracotomy (n=6) followed by harvesting of the lungs after 250min.
Results: BAL revealed a higher amount of protein content (p<0.05), cellularity (p<0.01) and relative neu-
trophil content (p<0.05) after thoracotomy with and without PA clamping compared to controls without
thoracotomy. The mean neutrophil count/HPF was higher after thoracotomy with and without PA clamping compared to controls without thoracotomy (p<0.05). The BAL profile and the mean neutrophilic
count after ischemia-reperfusion were not significantly different in animals with and without JNK inhibitor
pre-treatment.
No thoracotomy BAL protein (µg/ml) 0.63±0.40 BAL cells x 104/ml 54±22 BAL neutrophils (%) 4±2 Histology: mean 9.8±2.8 neutrophils count/HPF
Thoracotomy, no PA clamping
0.94±0.2 190±104* 23±19 * 30.6±3.6* Thoracotomy,
PA clamping
1.67±0.4* 324±91* 24±12 * 34±5.4* Thoracotomy, PA clamping,
+JNK inhibitor
1.68±0.5*
251±112*
31±21 *
31.3±3.3*
Conclusion: Thoracotomy and hilar dissection resulted in lung injury per se which is further increased
by ischemia-reperfusion. In this model, JNK inhibition was unable to prevent this essentially mechanical
damage.
7.5
ColoStim: colonic electrical stimulation reduces transit time in pigs
J. Vaucher, Y. Cerantola, J. Givel (Lausanne)
Objective: Chronic constipation (CC) is the most common digestive complaint in industrialized countries,
affecting 2-27% of the Western population and supposed to become an even more worrying medico-socio-economic problem. Today’s available conservative treatment of CC is unsatisfactory. Surgery might be
considered in refractory cases. However, it is poorly effective, irreversible, associated with high morbidity
and has a significant negative impact on quality of life. New perspectives in treating CC must therefore be
looked for. As electrical stimulation of the bowel might be an option to treat functional digestive disorders,
the ColoStim project aims to develop a battery-operated device able to reduce colonic transit time by
direct electrical stimulation. An experimental protocol was drawn, using adapted anesthesia parameters
and electrical pulse width, frequency and intensity able to generate colonic propagating waves. The goal
of this study was to demonstrate that our device can fasten bowel transit time in chronically implanted
pigs.
Methods: Three pairs of electrodes were implanted into the caecal wall, and wires exteriorized through the
abdominal wall. After 5 weeks, electrical stimulation was performed twice a day during one week. Bowel
transit time (TT) was evaluated by radio-opaque markers (ROM). They were given, respectively, the week
before implantation (physiologic, TT1), on the 4th week after implantation without stimulation (TT2) and
during electrical stimulation (TT3) (fig. 1).
Results: Mean physiological transit time, measured on 6 pigs, was 34h. There was no difference after
implantation (TT2= 35.6h; p= 0.779*). Stimulation of the caecum resulted in a significant reduction of
mean transit time, as calculated by ROM (TT3= 18.8h; p= 0.035*) (see tab. 1). These preliminary results
demonstrate that pig is an adequate model to evaluate the bowel transit time, which is reduced by caecal
chronic electrical stimulation. Moreover, histological findings showed no adverse effect directly related to
this stimulation.
Conclusion: With growing prevalence of CC, there is a need to develop new therapeutic modalities. Our research demonstrates that direct colonic stimulation could be an alternative to treat this condition. It might
also be used in treating spinal injured patients, since CC is commonly associated with this condition. A
fully laparoscopic/endoscopic implantable device has to be developed for human use.
7.6
Apolipoprotein E regulates hepatic lipid formation and gene expression in diet-induced steatohepatitis
P.C. Nett1, E. Haas2, T. Dorflinger2, H.R. Ha2, S.G. Shaw1, L. Tornillo3, J. Dufour1, D. Candinas1, M. Barton2
(1Bern, 2Zürich, 3Basel)
Objective: Although non-alcoholic steatohepatitis (NASH) is characterized by pathological alterations
ranging from steatosis and inflammation to cell degeneration, fibrosis and cirrhosis, the mechanisms
leading to NASH remain poorly understood, but appear to be associated with hyperlipidemia. This study
aimed to elucidate the role of apolipoprotein (apo)E in the pathogenesis of NASH in an experimental model of diet-induced steatohepatitis.
Methods: ApoE-deficient (apoE–/– ) and C57BL/6 wild-type mice as control were fed with a western-type
high fat diet for 30 weeks. Liver morphology, lipid content, plasma lipid levels, as well as gene expression
patterns of hepatic enzymes regulating the lipid metabolism were assessed by histology, high performance thin layer chromatography (HPTLC) and real-time PCR.
Results: Steatohepatitis was induced after 30 weeks of treatment in apoE–/– mice, which was correlated
with an increased hepatic content of triglyceride and cholesterol ester ( p<0.05), but not free cholesterol
(n.s.). Interestingly, hepatic content of triglyceride was decreased by almost 5-fold in apoE –/– mice in the
normal diet group (p<0.05), which was in line with a diminished expression pattern of genes regulating
hepatic lipid metabolism. Plasma levels of triglyceride, total cholesterol, VLDL- and LDL cholesterol increased in both wild type and apoE–/– mice in the high fat diet group (both p<0.05).
Conclusion: Our data indicate that apoE plays an important role in the lipid metabolism during the development of NASH affecting plasma lipid levels and hepatic lipid formation which regulates gene expression of hepatic enzymes controlling the lipid metabolism.
7.7
Thromboxane A2: a novel pathway of ischemia reperfusion injury in the macrosteatotic liver
A. Osman, J. Jang, A. Elsherbiny, W. Moritz, R. Graf, P.-A. Clavien (Zürich)
Objective: To investigate the hypothesis that omega-3 (n-3) polyunsaturated fatty acids (PUFAs) protect
the macrosteatotic liver against ischemia/reperfusion (IR) injury by modulation of arachidonic acid (AA,
n-6 PUFA) metabolites.
Methods: Two groups of ob/ob mice were fed either a standard laboratory chow or fish oil (a source of
n-3 PUFAs) enriched diet for 12 weeks. Hepatic content of n-6 PUFAs was measured. A model of partial
(70%) hepatic ischemia was applied for 45 minutes. Hepatic microcirculation and plasma levels of TXA2
in the suprahepatic vena cave were investigated. Hepatocellular injury was assessed by plasma levels of
alanine aminotransferase (ALT).
Results: Dietary supplementation with n-3 PUFAs resulted in a pronounced reduction in hepatic content of
arachidonic acid. After ischemia and 30 minutes of reperfusion, a significant rise in the vasoactive TXA2
levels was observed in the control diet fed animals with a remarkable decrease of the sinusoidal red blood
cell velocity and volumetric blood flow. Supplementation with n-3 PUFAs resulted in consistent reduction
of TXA2 levels after reperfusion. Microcirculation parameters were significantly ameliorated. Concurrently,
ALT levels disclosed pronounced reduction in n-3 PUFAs supplemented animals. The impact of TXA2 on
IR injury of the macrosteatotic liver was further highlighted by demonstrating a similar protection when
control diet fed animals were treated with a selective TXA2 receptor antagonist.
Conclusion: The increased susceptibility of the macrosteatotic liver to IR injury can be explained by the
damaging influence of TXA2 on hepatic microcirculation.
7.8
Computer-assisted digital image analysis of human islets
N. Niclauss1, M. Armanet1, Ph. Morel1, A. Sgroi1, R.M. Baertschiger1, A. Wojtusciszyn2, T. Berney1,
D. Bosco1 (1Genève, 2Montpellier/FR)
Objective: The aim of this study was to evaluate computer-assisted counting of human islets by digital
image analysis.
Methods: 41 human islet preparations isolated in our facility between August 2005 and June 2007 were
analyzed. Digital images of dithizone-stained islet samples were taken through a stereo-microscope. Fully
computerized counting was performed using the Offline MetaMorph Imaging Software for Microscopy.
Image analysis programs were developed to calculate total islet number, islet equivalent number (IEQ)
and islet purity. Manual counting was performed either using digital images (computer-assisted manual counting) or by direct microscopic analysis (conventional manual counting), in both cases with the
help of a calibrated measurement grid. The Ricordi algorithm was used for both fully computerized and
manual counting. Fully computerized IEQ counting was also performed using equivalent sphere, oblate
or prolate volume calculations. Results of fully computerized analysis were compared with computerassisted and conventional manual counting. Fully computerized counting was validated with red glass
microspheres of defined size.
Results: There was a good correlation between fully computerized counting and computer-assisted manual counting for total islet number, IEQ and purity with correlation coefficients of 0.98, 0.98, and 0.94
respectively, and nearly identical values. Correlation between fully computerized and conventional manual counting was lower (correlation coefficients: 0.75, 0.83 and 0.86, for total islet number, IEQ and
purity respectively), with nearly identical mean IEQ values. IEQ calculated using equivalent sphere volume
was 10 % lower (p<0.0001) than IEQ calculated with the algorithm. In contrast, IEQ were 20 and 60%
higher (p<0.0001) when calculated with prolate and oblate volumes than with the algorithm, respectively.
Analysis of glass microspheres showed a good correlation between fully computerized counting and
manual counting for total number, IEQ and diameter with correlation coefficients of 0.99, and near-identical values.
Conclusion: Computer-assisted digital image analysis is a rapid, objective and reliable method for analyzing pancreatic islets, which virtually eliminates operator-dependent variability. The method is validated
by volume calculations of defined size microspheres.
7.9
Human lung endogenous progenitor cells for treatment of emphysema
G. Karoubi, R.A. Schmid, L. Cortes-Dericks, I. Breyer, A.E. Dutly (Bern)
Objective: Lung emphysema is among the leading health problems worldwide with no effective treatments that can reverse the disease. Ultimately, the treatment for end-stage emphysematous lung disease
is lung transplantation with only a mean 5 year survival rate of just above 50%. The over-all results are
poor and morbidity rates among the patients who survive 5 years post-transplant are high due to secondary or underlying diseases. It is therefore imperative to find new therapies such as stem/progenitor
cell therapy for repair and regeneration of damaged emphysematous lung. Recent reports using animal
studies have suggested the existence of lung stem cell niches in select sites along the airway. The use
of endogenous progenitor cells however, has to date not been investigated in humans. In this project
we propose the isolation and characterization of human lung progenitor cells and assessment of their
engraftment in an animal model of emphysema in nude rats.
Methods: Human lung samples were collected in ice-cold saline and cells were isolated by enzymatic
digestion overnight. Cells were cultured, expanded and assessed for stem cell characteristics. Cells were
then fluorescently labeled and injected via the jugular vein into the pulmonary microvasculature.
Results: Primary cultures are found to be positive for the expression of the following stem cell markers:
CD34, CD133, CXCR4, and CD9 and OCT4. These cells are also positive for the embryonic stem cell transcription factor OCT4 and the multi-drug resistant protein ABCG2. Furthermore, in vivo results illustrate the
successful engraftment of the cells in the pulmonary microvasculature.
Conclusion: Our results demonstrate that endogenous lung progenitor cells can be isolated and expanded form intra-operative samples. These cells have illustrated strong progenitor cell properties in vitro and
25
may potentially be used as an effective therapeutic population of cells for the treatment of end-stage lung
emphysema.
7.10
MICA/B expression in renal cell carcinoma is not accompanied by NK cell infiltration but is associated
with CD16+ macrophage infiltration
G. Sconocchia, G. Spagnoli, L. Terracciano, E. Schultz-Thater, S. Wyler, L. Tornillo (Basel)
Objective: NK cell cytotoxicity is regulated by a balanced activation of killer inhibitory receptors (KIRs)
and natural cytotoxicity receptors (NCRs). The interaction of KIRs with major histocompatibility complex
I (MHC-I) determinants prevents NCRs activation while HLA-class I antigen loss triggers NCRs activation.
Expression of MICA/B, the ligands of NKG2D NCR has not been thoroughly investigated in renal cell carcinoma (RCC).
Methods: Expression of the genes under investigation was tested by quantitative real-time PCR (qRTPCR), whereas specific proteins were identified following staining with specific monoclonal antibodies by
flow-cytometry or immunohistochemistry (IHC).
Results: We utilized a RCC cell line, Caki-1, to evaluate the expression of MICA and MICB at gene and
protein levels. Caki-1 cells expressed MICA and MICB genes, and displayed a low cell surface expression
of MICB that could be enhanced by cell permeabilization. We then explored MICA/B expression in a RCC
tumor micro array (TMA) by IHC. All RCC tested (n=140) were strongly MICA/B positive. MICA/B was predominantly concentrated in the cytoplasm of tumor cells while stromal cells were negative. Surprisingly,
however, RCC lesions showed very low NK cell infiltration, as detectable by CD56+/CD16+ staining of the
same array. In contrast, RCC tissues were rich in CD16+CD56- cells, strongly resembling macrophages.
Most importantly, a high level of CD16+ macrophage infiltration was clinically relevant inasmuch as it was
more frequently detectable in metastatic lesions as compared to primary tumors (P=0.0223). In addition, it was also associated with poor RCC differentiation (P=0.007). To evaluate mechanisms potentially
responsible for the lack of NK cells infiltration in MICA/B positive RCC tissue, we hypothesized that upon
tumor and NK cell interaction, NK cell may be deleted through an apoptosis mechanism. Indeed, co-culture of IL-2 activated PBMC from healthy donors with Caki-1 cells resulted in the induction of apoptosis in
>50% of cytotoxic (CD56+CD16+) NK cells while regulatory (CD56+/CD16-) NK cells were unaffected.
Caki-1 dependent NK cell elimination was NKG2D, granule exocytosis and caspase independent.
Conclusion: Conclusions: Taken together these data unravel novel mechanisms possibly underlying escape of RCC cells from innate immune recognition.
7.11
Growth factor induced transmural neovascularisation of a vascular graft material to stimulate spontaneous graft endothelialisation
C. Schmidt1, N. Davies2, D. Bezuidenhout2, L. Higham2, P. Zilla2 (1Zürich, 2Cape Town/ZA)
Objective: The spontaneous endothelialisation of a synthetic vascular graft is a prerequisite for long-term
patency particularly in peripheral replacements. A possible source of endothelial cells (EC’s) would be the
microvasculature surrounding the graft. As this would require transmural migration of capillary derived
EC’s, we have developed a macroporous polyurethane (PU) graft material. We now report on derivatisation of the surface of this porous PU with Vascular Endothelial Growth Factor (VEGF) and Platelet Derived
Growth Factor-BB (PDGF-BB) to stimulate transmural neovascularisation
Methods: Heparin was attached covalently to PU discs (5.4 mm diameter, 2 mm thick) with well defined
open porosity (82% porosity, 157 ± 1µm pores) and VEGF165 and PDGF-BB were passively adsorbed.
Loading and release were determined by in vitro elution assays (ELISA). Heparinised discs containing
different concentrations of Growth Factors were implanted subcutaneously in rats for 10 days and vascular density was assessed by semi-automated microscopy on cross-sections after a-CD31 immunohistochemistry.
Results: A maximum of 1.2 µg VEGF165 was adsorbed per disc and took 48 hours to elute into PBS.
3.5µg PDGF-BB was loaded onto discs and only 2.9% was eluted after 7 days. Heparin surface modification alone increased vessel density by 77.64% compared to control (144.23 ± 24 vessels / mm2 vs. 81.19
± 6.06 vessels / mm2, p<0.05). Addition of PDGF-BB 3.6 µg further increased vessel density by 17.13 %
(168.94 ± 16.43 vessels / mm2 vs. 144.23 ± 24 vessels / mm2, p<0.05), and VEGF165 12 µg increased vessel density by 19.32 % (172.1 ± 20.95 vessels / mm2 vs. 144.23 ± 24 vessels / mm2, p<0.05).
The combination of 12 µg VEGF165 plus 1.8 µg PDGF-BB was most effective resulting in a 26.24 % increase in vessel density (182.08 ± 39.65 vessels / mm2 vs. 144.23 ± 24 vessels / mm2, p<0.05).
Conclusion: We could show that neovascularisation of porous PU as possible vascular graft material can
be successfully stimulated by heparin surface modification. The addition of growth factors such as VEGF
and PDGF-BB enhances this effect further. The positive outcome suggests that this approach may be
useful in transmural endothelialisation of porous vascular graft materials and thus may improve longterm
patency of synthetic vascular grafts.
7.12
The role of endothelial akt in allograft rejection
O. Dormond1, A. Contreras2 (1Lausanne, 2Boston/US)
Objective: The graft vascular endothelial cell (EC), by participating to all aspects of the immune response,
has been proposed to play a dominant role in the development of rejection. However, current models have
not tested in vivo the selective function of EC responses during the rejection process.
Methods: To test this, we used a double transgenic (DT) mice in which we can induce the expression
of the protein kinase Akt selectively in the endothelium under the control of tetracycline. In a fully MHC
mismatched model of cardiac allograft rejection, we analysed the specific role of graft endothelial Akt by
using double transgenic hearts as donors.
Results: The expression of Akt in the endothelium was confirmed by immunohistochemistry. We observed
26
that the overexpression of Akt in donor EC enhanced the recruitment of leucocytes within the graft at
day 3 and day 5 post transplantation compared to controls. This enhanced recruitment was associated
with increased transcription of several chemokines including IP-10 and MCP-1 as well as the adhesion
molecules ICAM-1 and E-selectin. In addition, we observed an increased number of activated CD8+/IFNg+ lymphocytes in the DT allografts as determined by flow cytometry and the frequency of IFN-g producing splenocytes was also increased in the recipients of DT allografts compared to control allografts. To
further evaluate the mechanism of action of Akt within EC, we isolated EC from double transgenic mice
and induced the expression of Akt by removing tetracycline from the culture medium. Akt expression was
confirmed by Western Blot. We found that Akt overexpression in EC resulted in an increased production of
chemokines such as IP-10 and MCP-1. Furthermore, in an in vitro assay, the transmigration of leucocytes
through an EC monolayer was increased by the overexpression of Akt within EC.
Conclusion: Taken together, these data show that the activation of Akt in the donor graft participates in
the recruitment of leucocytes and identify Akt as a target to inhibit EC activation responses during allograft
rejection.
7.13
Cancer stem cells features in established melanoma cell lines
R.M. Zimmerer, A. Barbero, X.S. Huber, P. Demougin, G. Iezzi, I. Martin, M. Heberer, G. Spagnoli (Basel)
Objective: Subpopulations of cancer cells are capable of reproducing tumors in immunocompromised
mice. Cancer stem cells (CSC) are usually rare in clinical specimens and hardly amenable to functional
studies or to analysis of gene expression profiles. We screened a panel of melanoma cell lines to identify cellular reagents sharing typical CSC features including expression of specific surface markers and
genes, capacity to grow in spheroids and to differentiate into multiple lineages, high clonogenic capacity
and resistance to treatment with cytokines.
Methods: D10, HBL, Me39, Me59, Me67, MZ2, Na8, RE and WM115 melanoma cell lines were studied.
Stem cell associated surface markers were analyzed by flow-cytometry. Clonogenic assays were performed by limiting dilution analysis (LDA) on cells sorted according to expression of selected markers.
Multilineage differentiation capacity was evaluated by culturing cell lines in the presence of media promoting osteogenic or adipogenic lineage differentiation. Gene expression profiles were assessed by using
real-time reverse-transcriptase polymerase chain reaction and Affymetrix GeneChip (Human Genome
U133A2.0) arrays.
Results: Na8, D10 and HBL cells, formed spheroids when cultured on plastic coated with poly-HEMA,
preventing cell attachment. In all lines except HBL ≥75% of cells expressed CD105 but only D10 cell line
expressed the classical CSC marker CD133. In contrast, only HBL cell line expressed CD117, a known
differentiation marker. In D10 line, CD133+ cells displayed a significantly higher clonogenic capacity as
compared to CD133- cells while CD105 expression was not associated with higher clonogenic capacity
in any cell line. Regarding their differentiation capacity, only NA8 cells were able to partially differentiate towards the adipogenic lineage upon appropriate stimulation. D10, Me39, RE and WM115 cells expressed
at least two of three genes, SOX2, NANOG and OCT4, involved in maintenance of stemness in mesenchymal stem cells. We addressed gene profiling of CD133+ and CD133- D10 cells. We found that 47
genes were up-regulated while 42 genes were down-regulated in CD133+ D10 cells (+/- 1.3 fold, < 0.01),
as compared to CD133- cells. A number of genes upregulated in CD133+ D10 cells, encode proteins
involved in cell proliferation including insulin-like growth factor-1, insulin-like growth factor binding protein
3 and PDGFc. Down-regulated genes included those encoding Tenascin C and TIMP-1. Among the cell
lines under investigation, HBL and Me67 were highly sensitive to IFN-_ treatment whereas D10 were fully
resistant to this cytokine. Intermediate sensitivities were detectable in the other cell lines.
Conclusion: Established melanoma cell lines exhibit to variable extents typical features of CSC. D10 cell
line, growing in spheroids, expressing CD133 and displaying a high resistance to IFN-_ treatment might
qualify as a potential “in vitro” model of melanoma stem cells.
7.14
Gastro-intestinal peptides before and after Laparoscopic Roux-Y Gastric Bypass (LRYGB) or Laparoscopic Sleeve Gastrectomy (LSG): early results of a prospective randomised trial
N. Devaux, C. Beglinger, B. Kern, T. Peters, C. Christoffel, R. Peterli (Basel)
Objective: In a prospective randomised trial comparing LSG and LRYGB in the treatment of morbid obesity, we examined the changes in the secretion of gastrointestinal peptides controlling appetite and satiety. What are the consequences of resection of the gastric fundus (LSG) compared to only bypassing it
(LRYGB)?
Methods: From 11/06 to 12/07 35 morbidly obese patients (m:f = 0.3), ageed 42 (23-60) y., with a
BMI of 46.8 (40-61) kg/m2 were randomised after evaluation by an interdisciplinary team and signed
informed consent. Plasma levels of Ghrelin, glucagon-like peptide-1 (GLP-1) and peptide YY 3-36 (PYY)
were measured before (-15, -1 min) and after (30, 60, 120, 180 min) a meal-stimulation with 400 kcal
preoperatively as well as 8-10 days and 3 months postoperatively. To date we have been able to analyse
5 patients per group.
Results: Prior to surgery ghrelin levels decreased very little, GLP-1 didn’t manifest any reaction and the
increase of PYY was poor after meal stimulation, showing a typical pattern of morbidly obese patients.
Postoperatively the fasting ghrelin levels of LRYGB-patients decreased by 30% 8-10 days postop and by
21% at 3 months postop. After LSG, patients had a regression of 46% of their fasting ghrelin-levels. After
meal-stimulation no changes could be observed in the ghrelin-levels at any time or any of the operations.
Other than preoperatively, GLP-1 showed a impressive elevation after stimulation, although the latter was
more important after LRYGB than LSG at 8-10 days (2470% vs 1586%, n.s.). 3 months postoperatively,
we were able to observe a similar and considerable increase in both (2588% after LRYGB vs 2382% after
LSG). The fasting PYY levels showed a decrease of about 28% after LRYGB compared to the preoperative
ones and 18% after LSG. After 8-10 days, PYY manifested an important postprandial increase of about
272% of the fasting value after both operations and of 231% for LRYGB-patients and 263% of LSG-patients 3 months postop.
Conclusion: LSG seems to be more efficient in reducing plasma Ghrelin levels than LRYGB. GLP-1 shows
a postprandial increase after both operations, however it takes 3 months after LSG to reach equivalent
levels compared to LRYGB. The PYY-increase after stimulation is significant and similar in both procedures. Resection of the fundus (LSG) compared to bypassing it (LRYGB) seems to have an impact on the
gastrointestinal peptide profiles.
7.15
Assesment and radio-histological correlation of different labelling agents for human islet imaging
F. Ris, M. Lepetit-Coiffe, C. Toso, M. Armanet, D. Bosco, Ph. Morel, J. Vallee, T. Berney (Genève)
Objective: Recent updates of the Edmonton protocol have shown that islet graft function progressively deteriorates over time after transplantation. Since rejection cannot be monitored after transplantation, there
is a crucial need for non-invasive assessment of the fate of islet grafts. The aim of the present study is to
compare the use of Resovist or Endorem (Ferridex) in term of toxicity, insulin response and iron uptake as
well as MRI imaging in vitro and in vivo.
Methods: For all experiment, we used human islet preparation of high purity level (80 to 90%). Human
islets were labelled with superparamagnetic iron oxide (SPIO) nanoparticles at different concentration
(Resovist (0.5, 2, 5 and 10 l/ml) or Endorem (100 or 200 g /ml) in CMRL-based culture medium) for 24
hours at 37°C. Static incubations were performed on 100 islets, comparing insulin response under basal
(2.8 mM ) or high glucose stimulation (16.7mM). Islet viability was estimated by staining with Viability
dead red solution. Insulin and Perl’s (assessment of iron content) staining were performed. Labelled Islets
were used for in vitro or in vivo imaging in MRI 1.5T.
Results: Labelled and control islets responded similarly to glucose stimulation during static incubation
tests. Both had stable viabilities between 80% to 90%. Exocytosis is preserved in all conditions. On histology, both iron particles were co-localized with insulin staining cells, but the uptake was very heterogeneous
within the same preparation. Endorem particles were observed in dead cells. MRI images of phantoms
correlated with the iron cell content, using both SPIO. However, Endorem demonstrated a less intense
signal as Resovist. After human islet transplantation in rats, the 1.5T MRI signal was strong with Resovist,
but weaker after Endorem labelling, even at the highest concentration (200 g /ml).
Conclusion: Resovist appears more appropriate for human islets imaging compared to Endorem. Both in
vitro (phantom) and in vivo (transplantation in rats) 1.5 T MRI assessment demonstrated sharper images
with Resovist. Both SPIO are non-toxic to the islets.
7.16
Increased total insulin content and restoration of first-phase insulin secretion in standardized small human pseudoislets
W. Moritz, R. Zuellig, G. Cavallari, R. Lehmann, M. Weber, P.-A. Clavien (Zürich)
Objective: Pancreatic islets can be dissociated into single cells and reaggregated into so called “pseudoislets”, which are morphologically equivalent to intact islets. Small islets are potentially less susceptible
to ischemic injury after intrahepatic islet transplantation and therefore a preferred subset of an islet isolate.
Here we describe a method to generate standardized pseudosislets of small dimensions. The cytoarchitecture and in vitro function of rat and human pseudoislets are compared.
Methods: Human islets were dissociated into single cells by trypsin treatment. Fractions with defined cell
numbers were seeded into single drops onto cell culture dishes which were inverted and incubated for 614 days under regular cell culture conditions. Newly formed pseudo-islets were analyzed for dimensions,
morphology, cellular composition and glucose stimulated insulin secretion.
Results: The volume of reaggregated pseudoislets strongly correlated with cell number. Morphology, cellular composition and cytoarchitecture of reaggregated human islets were comparable to intact islets. The
insulin secretory capacity of small pseudoislets (250 cells/islet) reached 88% and 160% (p<0.001) after
6 and 14 days of reaggregation culture, respectively, compared to mixed populations of intact fresh islets.
Compared to intact fresh islets, the stimulation index of pseudoislets was improved by 2.3-fold (p=0.007),
partially also due to a reduced baseline secretion. While first phase insulin secretion was nearly absent
in freshly isolated and cultivated intact islets, it was restored in small pseudoislets. Total insulin content
expressed per islet equivalent in intact and reaggregated pseudoislets was inversely correlated to the islet
size, with small islets storing up to 4-fold more insulin than large islets.
Conclusion: The superior biological function with respect to the total insulin content, first phase insulin
secretion, and stimulation index constitutes small human pseudoislets as an ideal source for the improvement of graft function in islet transplantation.
7.17
Gastrocolonic response in patient suffering from slow transit constipation as recorded by magnet tracking system
O. Gié1, V. Schlaegeter2, J. Vaucher2, P. Wiesel2, N. Demartines2, J. Givel2 (1Locarno, 2Lausanne)
Objective: Chronic constipation is a common medical problem, difficult to handle and costly. Physiopathology is still misunderstood; consequently therapeutic options are symptomatic and mostly not focused
towards aetiology. The gastro-colic response has been recognized for long as the major stimulus of colonic motility. Previous studies, based on manometry, demonstrated a reduction of this reflex in constipated
patients. An innovative technology, the Magnet Tracking System (MTS), has been used to analyse bowel
motility in constipation and to investigate gastrocolic response in such a situation.
Methods: MTS is based on the tracking of a magnetic pill moving with intestinal content. It permits to
locate the marker and display its activity in real time. Motility index (MI), quantifying magnet displacement
and rotations, refers to its deviation from a standard position. To evaluate gastro-colic response, recordings through the complete colon were performed, fasting and after food intake. Four patients completing
the Rome II criteria for slow transit constipation were selected and compared with nine healthy subjects.
According to a longer transit time, two days of investigation were planned for constipated patients and
one day for healthy volunteers.
Results: Important discrepancies in gastro-colic reflex have been measured between the different colon
segments of healthy volunteers. MI was higher in the ascending and descending colon after meal (mean
value: fasting=0.95, after feeding=2.36). This phenomenon was not seen in the transverse colon or splenic flexure (fasting=1.41, after feeding=1.16). In constipated patients, this reflex was absent throughout
the colon (fasting=1.15, after feeding=1.11). The segmental transit time was longer in constipated patients, in whom the pill was still located in the ascending colon 24 hours after ingestion, while in healthy
subjects, it reached the second half of the transverse colon after the same time
Conclusion: In our experience differences between constipated patients and healthy volunteers were
observed in both segmental transit time and food intake impact. However, the gastro-colic reflex was
only observed in the ascending and descending colon in healthy subjects and disappears completely in
constipated patients. The Magnet Tracking System allows an accurate non invasive and easy evaluation
of slow transit constipation. It permits to identify precisely any pathological colonic segment and, therefore
may lead to define a specific surgical treatment in selected cases.
7.18
Bone sialoprotein coating of materials does not improve osteogenic cell differentiation in vitro nor ectopic bone formation in vivo
S. Schaeren, C. Jaquiéry, F. Wolf, E. Schultz-Thater, M. Heberer, I. Martin (Basel)
Objective: Engineering cell-based bone graft substitutes requires the use of suitable scaffolds, capable
to ‘prime’ osteoprogenitor cells (e.g., bone marrow stromal cells, BMSC) to deposit bone matrix. As opposed to ceramic-based materials, scaffolds made of synthetic polymers without a calcium phosphate
component have clear advantages in terms of mechanical properties and handling, but have never been
reported to be osteogenic when loaded with osteoprogenitor cells. Bone sialoprotein (BSP) is an extracellular non-collagenous matrix protein playing a key role in the initial phase of deposition of a bone tissue
matrix. The goal of this study was to test the hypothesis that coating with BSP of different substrate materials will enhance BMSC differentiation in vitro and bone formation in vivo. In particular, we assessed
whether BSP coating of scaffolds made of synthetic polymers would make them osteogenic in an ectopic
model, when loaded with BMSC.
Methods: Tissue culture treated polystyrene 24-well plates, ceramic (b-tricalciumphosphate, OsteologicTM) and synthetic polymer (PolyactiveTM) discs of corresponding size were coated with human recombinant BSP in concentrations of 1 and 10ug/ml and analysed for the effective presence of BSP using
fluorescence microscopy and ELISA tests. Human bone marrow stromal cells (BMSC) were seeded in the
substrates and harvested after 10 and 20 days in culture with osteogenic medium. Real time RT-PCR was
used to assess the mRNA expression of osteogenic markers, namely BSP and osteopontin (OP). Porous
3D scaffolds made of the same ceramic and polymer materials as detailed above were also coated with
BSP, loaded with BMSC and implanted subcutaneously in nude mice. After 8 weeks, mice were sacrificed
and explants were assessed histologically and by computerized histomorphometry.
Results: Coating analyses confirmed the adsorption of BSP on the different substrates, in a dose-dependent fashion. BSP coating of ceramic and of synthetic polymer substrates up-regulated in vitro mRNA expression of BSP (by up to respectively 4.4 and 7.0 fold) and OP (by respectively 3.1 and 6.7 fold). However,
BSP coating did not increase the total amount of bone formed in vivo in ceramic-based scaffolds and did
not support bone formation using synthetic polymer scaffolds.
Conclusion: Despite the promising in vitro data, our results indicate that BSP coating of ceramic or synthetic polymer materials does not enhance in vivo formation of bone tissue. The study indicates that presentation of BSP to BMSC is not sufficient to prime their functional osteoblastic differentiation on polymeric substrates, and thus reinforces the importance of a ceramic component in a scaffold to be used for
BMSC-based bone tissue engineering approaches.
08
8.1
Schnellere Primärdiagnostik beim Polytraumapatienten mittels Spiral-CT im Schockraum
S. Shamdasani, A.L. Jacob, S. Hulliger, P. Regazzoni, M. Jakob (Basel)
Objective: Da bei der Versorgung polytraumatisierter Patienten der Faktor Zeit eine entscheidende Rolle
spielt ist es wichtig, möglichst schnell zu einer genauen Bildgebung zu gelangen. Der MBI des Universitätsspitals Basel („Multifunktioneller bildgestützter Interventionsraum“) fungiert als Schockraum mit
einem eingebauten CT Gerät. Ziel dieser prospektiven und randomisierten Studie war es darzustellen,
dass ein signifikanter Zeitgewinn dadurch erreicht werden kann, dass zum einen die räumliche Trennung
des Schockraumes aufgehoben wird und dass dadurch der Gebrauch eines Computertomogramms als
primäre Modalität zur schnelleren Diagnostik und Behandlung relevanter Verletzung führt.
Methods: Eingeschlossen wurden Patienten die mit dem Status „REA-Patient“ über den Notfall eingeliefert
wurden mit einem ISS von >15. Die Behandlung erfolgte nach ATLS Richtlinien in beiden Gruppen. Verglichen wurden zwei Gruppen: die eine Gruppe wurde im MBI, die Kontrollgruppe im Rea-Raum behandelt
wo die CT-Diagnostik erst nach der Primärstabilisierung (Primary Survey) durchgeführt wurde. Verglichen
wurden die Zeiten von Eintritt des Patienten bis zum Erhalt einer Diagnose bzw bis zum Ausschluss von
Verletzungen.
Results: Es wurden von 11/2006 bis 11/2007 41 Patienten eingeschlossen, davon 21 Patienten welche
im MBI behandelt worden sind und 20 Patienten welche im Rea-Raum behandelt wurden. Wir haben einen signifikanten Zeitunterschied (p < 0,05) zugunsten des MBI feststellen können beim Zeitvergleich des
Erhaltens der CT Bilder einzelnen Körperregionen. Weiter war ein signifikanter Zeitunterschied (p<0.05)
bei der Diagnose der Verletzung mit dem grössten AIS zu erkennen. Es konnten teilweise bis zu 16 Minu-
27
ten eingespart werden bei der Behandlung im MBI im Gegensatz zur Behandlung im Rea-Raum
Conclusion: Der signifikante Zeitunterschied zugunsten einer Behandlung im MBI kommt dadurch zustande, dass der Schockraum und das CT-Gerät räumlich nicht voneinander getrennt sind. Weiter ist eine
Ganzkörper-Computertomographie des Patienten als primäre radiologische Diagnostik bei Polytraumatisierten schnell und ohne grossen Aufwand durchführbar. Das ATLS-System definiert hinsichtlich der
radiologischen Diagnostik nur einen Mindeststandard mit konventionellen Bildern, diese haben aber nur
eine geringe Sensitivität. Das CT weist eine hohe Sensitivität auf und bietet durch den Scout eine Übersicht
über eventuelle Extremitätenverletzungen. Wir haben zeigen können, dass es einen eindeutigen Zeitgewinn darstellt, das CT im Schockraum zu haben und das Mehrschicht-Spiral-CT als Primärmodalität zu
benutzen. In den letzten Jahren ist die Primärdiagnostik Polytraumatisierter mittels CT immer mehr in den
Vordergrund getreten, so dass wir uns diesem Konzept anschliessen.
decreased below 2.5 mM/L within 24 hours. Overall mortality was highest in patients whose lactate values increased > 2.5 mM/L within 24 hours (25.0%). Length of hospital and ICU stay is shown in Figure
1. Patients with isolated traumatic brain injury did not follow these trends, yet 77.8% of TBI patients with
continuously high lactate values died within the first 72 hours.
Conclusion: Sequential lactate measurements during the initial 48 hours after admission provide a tool by
which to assess individual risk and adequacy of systemic resuscitation in trauma patients. Patients with
continuously high lactate values are at high risk of developing infectious complications and subsequent
organ dysfunction and failure due to persistent occult hypoperfusion. Length of hospital and ICU stay
correlates remarkably well with the initial 24 hour lactate clearance capacity. Patients with isolated traumatic brain injury, however, did not follow these trends and are less likely to benefit from sequential lactate
measurements during the initial resuscitation period.
8.2
8.5
Don’t be too fast in ruling out intra-abdominal solid organ injuries
L. Martinolli, A. Exadaktylos, H. Zimmermann (Bern)
Hemorrhage control in traumatic pelvic ring disruptions – a retrospective analysis of treatment parameters predictive of outcome
M. Keel, R. Abt, T. Lustenberger, M. Turina (Zürich)
Objective: The aim of this study was to investigate the diagnostic value of Focused Assessment with Sonography for Trauma (FAST) compared with computed tomography (CT) scan findings in multiple injury
patients with spleen and/or liver lesions.
Methods: This is a retrospective study of 226 multiple injury patients with liver and/or spleen injuries treated at the University Hospital Bern. The diagnostic accuracy of FAST was assessed in relation to the
severity of the organ lesions detected by CT scan.
Results: FAST failed to detect free fluid or organ lesions in 45 of 226 patients with spleen and/or liver
injuries (sensitivity 80.1%). Overall specificity was 99.5%. Grade III-V organ lesions were detected more
frequently than grade I and II lesions (Fisher exact test: spleen: p=0.007, liver: p=0.008). Without the additional diagnostic accuracy of a CT scan, the mean ISS (injury severity score) of the FAST-false-negative
patients would have been significantly underestimated (ISS with FAST alone=13.0 [SD 10.1], ISS with
FAST and CT=17.6 [SD 10.0]; Mann-Whitney test: p=0.009).
Conclusion: FAST examination failed to detect free fluid or organ lesions in every fifth patient with spleen
and/or liver injury, and reliably detected only grade IV and V lesions. From the clinical point of view, staging abdominal organ injuries with FAST is unreliable while an initial CT scan as a primary assessment
tool in multiply injured, hemodynamically stable patients provides superior diagnostic and therapeutic
certainty.
8.3
The severity of injury and the extent of hemorrhagic shock correlate with the incidence of infectious
complications in trauma patients
T. Lustenberger, M. Turina, L. Mica, M. Keel (Zürich)
Objective: Trauma patients are at high risk for the development of systemic inflammatory response syndrome (SIRS) and infections. The aim of the present study was to evaluate the influence of the severity of
injury and hemorrhagic shock at admission on the incidence of SIRS, infection and septic complications.
Methods: A total of 972 patients with an Injury Severity Score (ISS) of > 16, surviving more than 72 hours,
admitted to a level I trauma centre within 24 hours after trauma were included in this retrospective analysis. SIRS, sepsis and infection rates were recorded in patients with different severity of injury as assessed
by ISS, or with various degrees of hemorrhagic shock according to ATLS® guidelines. Results are considered significant if p<0.05.
Results: A direct correlation exists between the ISS and the rate of infections (R = 0.52) and septic complications (R=0.478, Figure 1) above an ISS of 16. With an ISS of 17-40 points, patients developed infectious and septic complications at an average rate of 41% and 19%, whereas at an ISS of >40 points,
56% developed infections and 38% became septic (p<0.01). Severe hemorrhagic shock on admission
is associated with an increased infection rate (68%) and a higher number of septic complications (43%)
compared to mild hemorrhagic shock (43% and 21%, respectively, Figure 2).
Conclusion: The severity of injury according to anatomic regions and the severity of hemorrhagic shock
are risk factors for the development of infectious and septic complications. Early diagnostic and adequate
therapeutic work up with planned “second look” – interventions may reduce these posttraumatic complications in severely injured patients.
8.4
Sequential lactate measurements are a significant prognostic factor in trauma patients, but less so in
patients with isolated traumatic brain injury
C. Dübendorfer, A. Billeter, M. Turina, M. Keel (Zürich)
Objective: The clearance of arterial lactate during the first 48 hours is known to correlate with successful resuscitation following major trauma. We have earlier reported that a significant correlation exists
between indadequate 24h-lactate clearance and the subsequent development of infectious and especially septic complications in trauma patients. The aim of the present study is to better elucidate the diagnostic value of serial lactate measurements in the initial time period following major trauma in different
subgroups of patients
Methods: All patients with an ISS > 16 (injury severity score) admitted within 72 hours to a level I trauma
centre were prospectively enrolled into our trauma data base. Late referrals were excluded from analysis.
Patients with isolated traumatic brain injuries (TBI) were separately analyzed. Parameters of interest included infection rates, sepsis, overall mortality, length of hospital- and ICU (intensive care unit) stay, and
length of mechanical ventilation. Data are stated as mean ± SEM and considered significant at p<0.05.
Results: 1495 patients (75% male) fulfilled the inclusion criteria for this study. Of these, 245 (16%) suffered from isolated traumatic brain injuries. Patients with continuously high (>2.5 mM/L) lactate levels
had the highest rate of sepsis (65.9%) as compared to 24.4% in those patients whose lactate values
28
Objective: Hemorrhage and uncontrolled shock remains the leading cause of death in patients with pelvic
fractures. The aim of the present study was to analyze parameters by which to predict fatal outcome
following stabilization of pelvic ring injuries by c-clamp and/or pelvic packing.
Methods: Forty-four patients with unstable pelvic ring injury and initial c-clamp application were included
in this retrospective analysis. In patients with persistent hemodynamic instability due to ongoing hemorrhage, laparotomy and pelvic packing were performed. Clinical, physiological and laboratory parameters
(lactate level, hemoglobine, prothrombine time etc) were prospectively recorded at admission and at various time points throughout the hospital stay. Groupwise comparisons were performed between patients
who survived at least 72 hours following injury and those that did not. Data are reported as mean ± SEM,
and considered significant at p<0.05.
Results: From a total of 44 affected patients, 29 patients survived at least 3 days, whereas 15 patients did
not. The two groups did not differ with respect to age, gender, and interestingly, time until admission. The
average ISS was 41.9 ± 5.4 in patients who died and 35.0 ± 2.6 in those who lived (p=0.11). A significantly higher percentage of patients (73%) who died suffered from severe shock (class IV according to ATLS),
as opposed to only 7% of survivors (p<0.001). Parameters of occult hypoperfusion (ph, base excess,
lactate) were generally worse in non-survivors than in survivors (Table 1). With respect to serial lactate
measurements, greatest differences were recorded at 2h following admission, when inadequate resuscitation and tissue perfusion led to excessively high lactate values in non-survivors (10.1 ± 2.0 mmol/l vs.
4.9 ± 0.5 mmol/l, p<0.001). Table 1. Overview of Patient Collective.
Non-Survivors (n=15) Survivors (n=29) Age (years) 42.9 ± 7.9 44.6 ± 3.4 Gender (Male) 9 (60%) 15 (52%) Hours until admission 1.4 ± 0.2 1.8 ± 0.2 Outside Referrals 0
10 (34%) Air Rescue 6 (40%) 15 (52%) Pelvic Tamponade 10 (66%) 12 (41%) Injuries Sustained (incl. Pelvic Ring Injuries According to Tile et al.)
ISS 41.9 ± 5.4 35.0 ± 2.6 Traumatic Brain Injury (AIS > 2) 7 (47%) 10 (34%) Type B Pelvic Ring Injuries 4 (27%) 3 (10%) Type C Pelvic Ring Injuries 10 (73%) 26 (90%) Hemodynamics and Tissue Oxygenation
pH 7.0 ± 0.1 7.2 ± 0.1 Base Excess -14.4 ± 3.7 -5.7 ± 0.9 Lactate 7.2 ± 1.4 4.1 ± 0.5 MAP 70.7 ± 10.0 83.3 ± 3.6 Syst. BP 99.0 ± 14.6 113.2 ± 4.3 Shock Class (ATLS)
Shock I 0
6 (21%) Shock II 0
13 (45%) Shock III 4 (27%) 8 (27%) Shock IV 11 (73%) 2 (7%) p
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
0.04
<0.001
0.001
0.06
ns
0.08
0.002
ns
<0.001
ISS, injury severity score; AIS, abbreviated injury scale; MAP, mean arterial pressure; BP, blood pressure;
shock classification according to ATLS.
Conclusion: Early control of hemorrhage or the lack thereof is fundamental for prognosis after severe
pelvic trauma. Factors such as age, the exact type of pelvic injury or the presence of concomitant injuries
are second in importance to the extent of hemorrhagic shock and its timely correction. The application
of pelvic clamps and early pelvic tamponade in actively bleeding patients are crucial during the early
management period. Serial lactate measurements allow indirect monitoring of tissue oxygenation and
resuscitation efforts and may help in the surgical decision making process.
8.6
Can RapidTEG® revolutionize the search for coagulopathies in the multiply injured patient?
V. Jeger, A. Exadaktylos, R. Kretschmer, H. Zimmermann (Bern)
Objective: Coagulopathy in trauma is a major problem in treatment of multiply injured patients. We have
shown in a retrospective analysis, that one third of multiply injured patients (ISS > 15) suffer from coagulopathy. Conventional coagulation screening tests (INR, aPTT, TT) measure only isolated steps of the
coagulation cascade and take long time until results are available (more than 60 minutes). Alternatively,
conventional thrombelastography, which is well known in liver and cardiac surgery, analyze every step of
the cascade but take also up to 40 minutes. Recently, a new reagent is on the market called RapidTEG®
(coagulation activated by the use of tissue factor), which focuses mainly on the clot strength and provides
information within minutes
Methods: 20 prospective, consecutive multiply injured adult trauma patients (age > 16, ISS > 15). Device:
TEG® 5000 (Haemoscope Corporation, Niles, IL) based in our resuscitation room.
Results: We evaluated TEG in 20 (m=13, f=7) trauma patients. Median ISS: 29. Median age: 47 (range
16 to 87). We started TEG analysis 11 minutes (median, range: 2 – 18) after admission of the patient to
ER. Information about the clot strength has been obtained 10 minutes after starting analysis. 50% were
pathological, TEG based, thereof only 3 had pathological standard coagulation tests.
Conclusion: Uncovering trauma related coagulopathies is one of the major goals during the resuscitation
period and rapid TEG seems to be a new suitable technique. The clinical importance of the TEG based
findings need to clarified.
8.7
Mortality in 186 polytrauma patients with liver injury: the role of collateral injuries
M. Schafer1, B. Schnueriger2, J. Kreutziger2, J.M. Heinicke2, C.A. Seiler2, D. Inderbitzin2, D. Candinas2 (1Biel,
2
Bern)
Objective: The aim of the presented study was to analyse causes of early and delayed deaths in trauma
patients with concomitant liver injuries (LI).
Methods: The study was conducted at the Inselspital, Bern University Hospital, Switzerland between January 2000 and December 2006. Patient charts were reviewed retrospectively.
Results: The overall cohort mortality was 16.7% (31 of 186). The mean ISS for the survivors and non-survivors was 24.7 ± 11.4 and 40.2 ± 9.8, respectively (p<0.0001). Purely early liver related overall mortality
was 3.2% (6 of 186). All these six patients suffered grade 4 and 5 hepatic lesions and died during or
immediately after prompt laparotomy. Of note, all of them additionally required emergency thoracotomy
due to accompanying pulmonary or mediastinal bleedings, aortic cross-clamping or for open-chest cardiopulmonary resuscitation. A total of 10 patients with LI died early after admission by other causes of
exsanguination. Those collateral injuries are shown in detail in the table below.
Cause of death Splenic and renal rupture (grade 4, 5) Rupture of iliac artery Intra-thoracic aortic rupture Cardiac rupture Severe pulmonary lazeration Total n=
2
2
3
1
2
10
In the course of the hospitalisation, 15 more patients died due to delayed complications: 7 patients with
severe cerebral edema after head injuries, 6 patients suffered fatal pulmonary embolism and 2 patients
died from multi-organ-failure and sepsis. The period of time from the accident until admission was for the
survivors and the non-survivors 154 ± 132 minutes and 139 ± 188 minutes, respectively (p=0.6885). In
total 25 (80.7%) out of 31 patients died within the first 24 hours after the accident.
Conclusion: Since the 90’s mortality in liver injured patients stagnates at about 15%. Our data reveal that
80% of causes for death in patients with LI were brain and thoracic injuries with their complications or
exsanguination by collateral injuries. That exemplifies the complexity of trauma patients with LI. To decrease the mortality in those patients, the trauma surgeon should be aware of collateral injuries and their
management should be of superior priority.
8.8
Ist die Mortalität sekundär verlegter, schwerverletzter Patienten (ISS >16) höher als diejenige primär in
einem Traumazentrum versorgter Patienten?
R. Soyka, A. Exadaktylos, R. Schröder, H. Zimmermann (Bern)
Objective: International gilt, dass die primäre Versorgung des schwerverletzten Patienten im Zentrumsspital zu erfolgen hat. Wir gehen der Frage nach, ob es in unserem Einzugsgebiet einen Zusammenhang
zwischen der Wahl des primären Zielspitals und der Mortalität der Patienten gibt.
Methods: Einzugsgebiet des Universitätsspitals Bern. Für diese prospektive Studie erfassten wir in der Zeit
vom 17.08.2002 bis zum 17.12.2004 Daten von Patienten > 16 Jahren, welche mit Verdacht auf Mehrfachverletzung entweder direkt oder via peripheres Traumazentrum in den Schockraum des Inselspitals
eingewiesen wurden (n=873, Patienten mit ISS > 16 n=342). Die Datenerhebung und -Analyse erfolgte
mittels Fragebogen und spitalinterner Statistikauszüge.
Results: TRANSPORTWEG UNFALLORT -> UNIVERSITÄTSSPITAL: Über peripheres Spital: 18%; Inselspital
direkt 82% ZEIT (min) UNFALLEREIGNIS -> EINTREFFEN SCHOCKRAUM Über peripheres Spital: 238 ±222
(mean/SD), Median 177,5 Inselspital direkt: 95 ±86 , Median 80 INJURY SEVERITY SCORE: (Mittelwerte
nicht signifikant verschieden: p=0, 2424) Über peripheres Spital: 29,84 ±12,68, Median 27 Inselspital
direkt: 32,03 ±14,32, Median 27 MORTALITÄT IN BEZUG AUF TRANSPORTWEG: Gesamt: 21,4%, Über periphere Klinik 11%; Inselspital 23%;
Conclusion: Kleine Traumazentren im Kanton Bern leisten hervorragende Arbeit bei der Erstversorgung
schwerverletzter Patienten. Die Erstversorgung in der Peripherie und der dadurch resultierende Zeitverlust
scheinen keinen Einfluss auf die Mortalität zu haben. Wenn eine direkte Verlegung ans Zentrum (Wetter,
Infrastruktur etc.) nicht möglich ist, können diese Patienten in einem peripheren Spital stabilisiert werden.
Weiterführende Studien, welche die Morbidität und das Langzeit-outcome der versorgten Patienten untersuchen, sollten durchgeführt werden.
8.9
How can we on screen identify injured skiers and snowboarders who need tertiary trauma care?
R. Hasler, T. Franz, H. Zimmermann, A. Exadaktylos (Bern)
Objective: OBJECTIVE: On-pist triage is an extremely difficult task for rescuers and paramedics. Unfortunately, many patients with severe pelvic, thoracic, head and spinal injuries are initially transferred to minor
trauma centers before being referred to definitive tertiary care. Delays in appropriate refferal are related
with increased morbidity and mortality. We therefore evaluated epidemiological data and injury patterns
of severely injured alpine skiers and snowboarders and analyzed “injury key patterns” for more effective
on-pist triage and referral to definitive care.
Methods: A six year review of all patients with severe injuries sustained from alpine skiing or snowboarding. All adult patients (age over 16 years) admitted to a tertiary trauma center from July 1, 2000, through
June 30, 2006, were reviewed using a computerized database. A total of 728 patients injured from snow
sports were identified. Relevant trauma - defined as 1) head, 2) thoracic, 3) abdominal, 4) pelvic or 5)
spinal trauma - was found in 328 patients. We tried to identify the most risky combinations of injuries
sustained by skiers and snowboarders.
Results: As estimated the majority of injuries (n = 256, 78%) were single-site injuries with only one part
of the body injured. In 22% we could identify combinations of two sites of injury at least. Noteworthy, thoracic injury revealed in 63% and pelvic lesion in 48% to coincidence with further trauma, particularly with
head and spine. Abdominal trauma appeared in 72% as multi-site injury, especially associated with head
lesions (22%). However, over all the most common combination was head and spine, which means that
13% of spinal trauma patients at mean time suffered from head trauma (CI 7.69-19.29).Finally we could
define 4 “Key injury patterns”: 1) Spine associated with head (13%, CI 7.69-19.29), 2) Thorax associated
with head (24%, CI 14.09-35.38), 3) Pelvis associated with spine (12%, CI 2.55-31-22) and 4) Abdomen
associated with head (22% CI 6.41-47.64).
Conclusion: With advances in technology and slope maintenance, skiers and boarders progress to higher skills, faster speeds and greater risks more rapidly than ever before. Patients in whom either head,
spine, thorax, pelvis or abdomen seems to be injured, bear a high risk of a severe associated injury. Being
aware of the „key injury patterns” injured skiers and boarders could be faster referred to the most appropriate trauma center.
10
Thoracic Surgery
10.1
Spontaneous chylo-pneumothorax associated with pulmonary lymphangioleiomyomatosis in a young
female patient
W. Oulhaci, A. Blaser (Nyon)
Objective: A case report background spontaneous pneumothorax occurs more rarely in females than in
males, and is usually not associated with chylothorax.
Methods: Case report A 33 year-old nulliparous no smoking woman presented with dyspnea related to a
first spontaneous left chylo-pneumothorax. A conventional chest ct-scan showed apical emphysematous
bubbles. A surgical pleurodesis with a wedge resection of the apical segment was performed because of
the persistance of the chylo-pneumothorax in spite of pleural evacuation with a Monaldi drain. Pathologic
examination of the lung specimen reveald typical lesions of pulmonary lymphangioleiomyomatosis.
Results: –
Conclusion: Discussion pulmonary lymphangioleiomyomatosis (LAM) is a rare disorder characterized by
proliferation of abnormal smooth muscle cells leading to the formation of lung cysts. It primarily affects
fertile women. Secondary spontaneous pneumothorax in LAM is the most frequent presentation. Chylothorax may occur. Pneumothorax and pleural effusion result from the underlying pathophysiology of LAM.
Pleurodesis is recommended for the initial pneumothorax due to the high reccurence rate. The condition
is potentially serious since pneumothorax often recurs in spite of surgery, leading about 20% patients to
lung transplantation.
10.2
Neuroendocrine tumors after lung transplantation
P.O. Myers, P.M. Soccal, J. Robert, F. Triponez, J. Pache, M. Bongiovanni (Genève)
Objective: Many types of tumors have been reported in transplant recipients. We report two cases of
neuroendocrine tumors encountered in our daily clinical practice after lung transplantation, and review
the literature on these rare tumors after solid organ transplantation.
Methods: We searched for all patients who developed neuroendocrine tumors after lung transplantation
in our institution over the past 15 years. We performed 110 lung transplantations from June 1993 through
June 2007. The Israel Penn International Transplant Tumor Registry was queried to find other cases.
Results: Chart searches revealed two cases of neuroendocrine tumors after lung transplantation. Queries
to the Israel Penn Registry did not reveal any further cases. Patient 1: A 59-year-old male was found to
have a villous polyp of the proximal duodenum on endoscopy, 4 years and 6 months after bipulmonary
transplantation for smoking-related pulmonary emphysema. Biopsy revealed a duodenal well differentiated neuroendocrine tumor. Octreotide scintigraphy was negative. Abdominal ultrasound and MRI did not
reveal any suspect mass. There was no recurrence of the neuroendocrine tumor at six months endoscopy. Duodenal well differentiated endocrine tumor. Cells are arranged in a tubulo-glandular pattern: nuclei
are uniform, round to oval with inconspicuous nucleoli and the cytoplasm is clear and eosinophilic. Inset
shows the cytoplasmic immunostaining of the cells for chromogranin A. Patient 2: A 58-year-old male,
underwent right lung transplantation for alpha-antitrypsine deficiency-related pulmonary emphysema.
29
Routine bronchoscopic examination at one month after transplantation was normal. Transbronchial biopsy revealed a well differentiated neuroendocrine proliferation (tumourlet vs typical carcinoid) of the
transplanted lung. Subsequent bronchoscopic and chest CT follow-up to 18 months did not reveal any
solid masses of the transplanted lung and no tumoral tissue was ever retrieved at biopsy. Pulmonary well
differentiated endocrine tumor (typical carcinoid). Cells infiltrate the submucosa in this transbronchial
biopsy showing the classical appearance of neuroendocrine cells. The nuclei are round, monotonous
and the chromatin is delicate, cytoplasm is eosinophilic. Inset shows the membranous immunostaining
of the cells for CD56.
Conclusion: We report the first cases of well differentiated neuroendocrine tumors arising after lung
transplantation. Except for the highly malignant small and large cell carcinoma, neuroendocrine tumors
generally demonstrate low malignant potential. It is not known, however, if this potential is different in
immunosuppressed patients. The two presented cases are particular, in that the tumor is derived from
the recipient tissue 4 years after transplantation in one of the cases; in the other case, the tumor was diagnosed almost by chance on bronchoscopic biopsy early after transplantation and developed from the
donor organ. Neuroendocrine tumors after solid organ transplantation are rare and their clinical evolution
is unknown, but appears similar to that in the immunocompetent patient.
10.3
Fatal cardiac herniation after blunt traumatic rupture of the pericardium
S. Rohrhuber, M. Brodmann-Maeder, R. Fakin, R.A. Schmid, G.L. Carboni (Bern)
Objective: Cardiac luxation after blunt thoracic trauma is rare and associated with a high letality. Most
physicians are unfamiliar with the clinical presentation, which is frequently confusing in the setting of a
multiple trauma. Therefore the diagnosis is frequently missed or found at autopsy.
Methods: We discuss the clinical and radiological signs suggesting pericardial rupture and possible therapeutic interventions on the base of a case report.
Results: A 52 year old male patient was admitted after severe multiple trauma following a fall from a
height. Initial assessment showed several clinical signs suggesting possible pericardial rupture. After
initial stabilization a sudden and rapid hemodynamic deterioration occurred in the CT-scan. Left sided
resuscitative emergent thoracotomy on site showed cardiac herniation through a anterolateral pericardial
tear with subsequent ventricular fibrillation. Even after reposition of the luxated heart, completion pericardiotomy, open cardiac massage and defibrillation, ventricular fibrillation persisted and the patient did not
reach sufficient cardiac activity which warranted discontinuation of further resuscitative measures.
Conclusion: Cardiac herniation although rare should be suspected in blunt traumatic chest injury in patients whom hemodynamic instability occurs rapidly without signs of pericardial tamponade or ongoing
major bleeding. Prompt surgical intervention may achieve good results depending on associated injuries
and extent of the direct damage to the heart
11
11.1
Sentinel lymph node procedure in resectable colon cancer – results from the prospective swiss multicenter study
C.T. Viehl1, U. Güller1, R. Cecini2, I. Langer3, A. Ochsner4, L. Terracciano1, H.M. Riehle1, U. Laffer2,
D. Oertli1, M. Zuber4 (1Basel, 2Biel, 3Lausanne, 4Olten)
Objective: The value of sentinel lymph node (SLN) procedure in colon cancer patients remains a matter of
debate. Therefore, the objective of this large prospective, multicenter trial was to evaluate the identification
rate and accuracy of the SLN procedure for colon cancer patients; to analyze factors influencing the SLN
procedure; and to assess the extent of upstaging due to the SLN procedure.
Methods: One hundred and seventy-four patients with biopsy proven, resectable colon cancer (stage I:
n=32, stage II: n=78, stage III: n=64) underwent open colon resections at three different centers. In vivo
SLN procedure was performed according to a standardized protocol: isosulfan 1% (median 2 ml, range
0.2-10 ml) was injected around the tumor, and blue staining lymph nodes were tagged and processed
separately. Three levels of each SLN were stained with H&E and immunohistochemistry (IHC) with the
pancytokeratin marker AE1/AE3. Groups were compared using the chi-square test, and Student’s t-test.
Results: SLN identification was successful in 155/174 patients (identification rate 89.1%). The accuracy
of the procedure was 83.9%, sensitivity 55.4%, specificity 100.0%, and negative predictive value 79.8%.
Identification rate (p=0.021), and sensitivity (p=0.043) significantly improved with center experience. Additionally, successful SLN identification depended on the intraoperative identification of blue stained lymphatic vessels (p<0.001). Median number of sampled SLN was 3 (range 1-20), and median number of
Non-SLN was 20 (range 1-57). False-negative results were significantly more frequent in pN1 compared
to pN2 patients (p=0.004), and when fewer SLN were identified intraoperatively (p=0.026). In total, 4,000
lymph nodes were analyzed (562 SLN, and 3,438 Non-SLN). SLN were significantly more likely to contain
tumor infiltrates than Non-SLN (p<0.001). Small nodal tumor infiltrates were found in SLN, due to the use
of IHC, in 16 of 104 stage I and II patients considered node-negative in initial H&E analysis thus resulting
in upstaging of 15.4% of these patients.
Conclusion: The sentinel lymph node procedure for resectable colon cancer has good identification and
accuracy rates. However, several factors influence the success of the procedure and warrant attention.
Most importantly, the SLN procedure results in upstaging of over 15% of stage I and II patients, who might
therefore benefit from adjuvant chemotherapy.
11.2
Quality of surveillance after curative surgery for colon cancer
A. Ochsner1, U. von Holzen2, C.T. Viehl1, R. Cecini3, U. Güller1, I. Langer4, U. Laffer2, D. Oertli1, M. Zuber2
(1Basel, 2Olten, 3Biel, 4Lausanne)
10.4
Inflammatory myofibroblastic tumor (IMT) mimicking pneumatocele
F. Vauclair, I. Letovanec, S. Schmidt, B. Egger, H.B. Ris, T. Krueger (Lausanne)
Objective: We describe a case of IMT with atypical presentation.
Methods: A 28-year-old healthy woman consulted the emergency department for minor haemoptysis.
She suffered from tachypnea and chest discomfort for one year. The chest CT scan revealed a left lower
lobe cystic lesion of 1,5 cm close to a branch of the left lower lobe pulmonary artery. Bronchoscopy was
normal. Pneumatocele was suspected and follow-up was organised. One year later, a new CT scan
showed no change and clinical follow up was uneventful. However, on patient’s demand, left lower lobectomy for complete resection of the cystic lesion was performed. Histology revealed an inflammatory
myofibroblastic tumor of the lung, centered on a vessel. The patient had an uneventful recovery.
Results: IMT is a rare tumor most commonly observed in the lung. Its aetiology is controversial. Regarding
radiological findings, reports typically describe a nodular lesion or mass. In our case, the IMT presented
as a cystic pulmonary lesion mimicking a pneumatocele or a bronchogenic cyst.
Conclusion: This atypical presentation may lead to an inappropriate therapeutic approach, since benign
entities like pneumatoceles or bronchogenic cysts can be followed up, whereas IMT should be resected.
10.5
Taurolidine in the prevention of lung metastases
B. Hoksch, B. Rufer, A. Gazdhar, R.A. Schmid (Bern)
Objective: Taurolidine was first described as an anti-bacterial substance and mainly used in the treatment
of patients with peritonitis. Meanwhile, according to quite interesting new experimental findings, Taurolidine seems to affect tumor growth. This study examined the effect of administration of Taurolidine on the
establishment of lung metastases.
Methods: BD IX rats (n=13) were randomized into two therapy groups and one control group. All animals received 106 rat colon adenocarcinoma cells (DHD/K12/TRb) intravenously (jugular vein) at the
beginning of the procedure. According to the randomization, the rats were administered taurolidine via
osmotic pump (7 days, continously 2 ml 2% Taurolidine) at different time: either with the day of tumorcell
injection (group I) or 14 days later (group II). After 21 days, the animals were sacrified and the influence
of Taurolidine on metastases growth in the lungs were analyzed.
Results: More tumors were found in the control group compared to both Taurolidine groups as well in
expanse of tumour cells as in the quantity of tumour cells (p = 0.036 / p = 0.018 and p= 0.018 / p=
0.018). Metastatic tumor formation was also more extensive in group II compared to group I but without
significance.
Conclusion: Regardless of the small number of animals in this study it appears that taurolidine can (significantly) reduce the growth of lung metastases as well as the development of these metastases from
circulating tumor cells. The data are of significant interest for the management of patients undergoing
tumor resection. The results should be confirmed by a larger study.
30
Visceral Surgery
Objective: There is evidence that patients benefit from intensive surveillance after curative surgery for
colon cancer. The Swiss Society of Gastroenterology regularly publishes the current Swiss recommendations for surveillance after curative resection for colorectal cancer. However, data on the actual surveillance performed in comparison to the recommendations are scarce. We therefore analysed the quality
of surveillance of colon cancer patients according to the Swiss recommendations in the regions of BaselCity, Olten, and Biel.
Methods: The data used in this study are based on the follow up of patients enrolled in the Swiss multicenter trial “Sentinel Lymph Node Procedure in Colon Cancer”. All patients underwent curative surgery for colon cancer and provided written informed consent. Patients who deceased within 30 days after surgery,
patients refusing surveillance, and patients who did not qualify for surveillance due to old age and severe
comorbid conditions were excluded from this analysis. The parameters analysed were: measurements
of carcinoembryonic antigen (CEA), diagnostic imaging (sonography [US] or computed tomography
[CT]), and colonoscopy. All inpatient and outpatient files were reviewed and the treating physicians, gastroenterologists and patients received a questionnaire. In addition, all alive patients were contacted by
phone at the time of follow up. We compared the actual surveillance during follow up to the surveillance
recommended by the Swiss Society of Gastroenterology. We also compared the surveillance between
subgroups of patients who did and did not undergo adjuvant chemotherapy.
Results: Data of 129 patients (75 male, 54 female) were analysed. The median age was 72.7 years (range 27.3-92.2) and the median follow up was 33.5 months (5.6-74.7). Tumor stages according to UICC
were: Stage I 18% (n=23), stage II 46% (n=59) and stage III 36% (n=47). Fourty-four (34.1%) patients
were treated with adjuvant chemotherapy. Eleven patients (8.5%) died during follow up. The percentages
of patients with optimal surveillance according to the recommendations of the Swiss Society of Gastroenterology were 36.4%, 31.7%, and 23.8% for measurements of CEA, for imaging with US/CT, and for colonoscopy, respectively. For patients undergoing adjuvant chemotherapy the compliance with the current
recommendations was clearly better (56.4%, 42.8%, and 40% for CEA, for US/CT, and for colonoscopy
respectively) compared to patients who did not receive adjuvant chemotherapy.
Conclusion: The quality of surveillance according to the Swiss recommendations after curative surgery
for colon cancer is poor. Further education regarding the potential benefits of surveillance after curative
surgery for colon cancer is critical.
11.3
Dynamics of local and systemic recurrent disease after curative resection for colon cancer
F. Marra, T. Steffen, N. Kalak, R. Warschkow, J. Lange, M. Zünd (St. Gallen)
Objective: Reported rates of recurrent disease after curative resection for colon cancer vary considerably
in the literature. Furthermore, differentiation between systemic recurrences is poorly described. Only few
data about the dynamics of recurrent disease is provided for colon cancer, whereas many studies provide
data for either colorectal or rectal cancer. The aim of this study was to determine the chronological dynamic of recurrent disease after curative resection for colon cancer. Differentiation of local and systemic
recurrence was specifically regarded.
Methods: Medical records of a cohort of 445 consecutive patients undergoing curative resection for colon cancer with primary intraperitoneal anastomosis above the pelvic peritoneal reflection, performed
between July 1991 and December 2004, were reviewed. To achieve best possible data quality, the study
sample was limited to patients with colon cancer by intention. Therefore patients with rectal cancer were
not included. Local recurrence was defined as disease at the anastomosis or in the adjacent tissue. Systemic recurrence was defined as metachronous metastasis, and discrimination of location was considered
for statistical analysis. Using the product-limit method (Kaplan-Meier), the cumulative hazard curve was
generated for analysis of the dynamics of recurrent disease.
Results: The study population comprised 271 men and 174 women. The mean age was 68.6 years. Median follow-up was 66.5 months. Five-year-overall local recurrence rate was 5.7%, significantly depending
on primary tumour classification (pTN) (p<0.01, Table 1). Five-year-overall systemic recurrence rate was
11.3% (liver: 6.0%, lung: 3.5%, peritoneum: 2.8%) The cumulative hazard for local recurrence increases
rapidly initially during the first four years and flattens out in the further course. Identical dynamic was
found for metachronous liver metastasis. However, the dynamic for metachronous lung and peritoneal
metastases increases more slowly in a linear fashion over time (Table 2). Table 1: 5-y-overall local recurrence rate depending on pTN-classification.
5-y-overall local recurrence rate 0.0% 4.6% 3.9% 24.8% 2.0% 7.6% 18.8% 11.6
pTN-classification
pT1
pT2
pT3
pT4
pN0
pN1
pN2
Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection
U. Zingg1, D. Miskovic2, C.T. Hamel1, L. Erni3, D. Oertli1, U. Metzger3 (1Basel, 2Frimley, Camberley/UK,
3
Zürich)
Table 2: Cumulative hazards for metachronous liver and lung metastases over time
cumulative hazard for
metachronous liver metastasis
2.6% 4.4% 5.1% 6.0% 6.0% cumulative hazard for metachronous lung metastasis
0.3% 0.9% 1.7% 3.0% 3.5% between November 2002 and December 2007 were prospectively entered into a computerized database. Uni- and multivariate analysis of various clinical parameters were performed using Cox regression
model.
Results: Four hundred sixty-two emergency colonic resections were performed (33 ileocecal; 128 right;
7 transverse; 38 left; 48 sigmoid; 43 subtotal; 17 low anterior; 142 Hartmann; and 6 proctocolectomies).
The median age of patients was 73 (range 17-98) years, and 251 of them (54%) were classified as ASA 3
or more. The most common indications for surgery were: 171 adenocarcinomas (37%); 129 complicated
diverticulitis (28%); and 35 colonic ischemia (7.5%). The median operating time was 180 minutes, and
the median duration of hospital stay was 15 days. Overall mortality and morbidity rates were 14% and
48%, respectively. The anastomotic leak rate was 8.6 % (20 leaks out of 231 anastomoses). In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss
>500cc (OR=3.33, 95% CI 1.63-6.82, p=0.001). There were three parameters which correlated with postoperative morbidity: ASA score >3 (OR=2.9, 95% CI 1.9-4.5, p<0.001); colonic ischemia (OR=3.4, 95% CI
1.4-7.7, p=0.006); and stoma creation (OR=2.2, 95% CI 1.4-3.4, p=0.0003).
Conclusion: The main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: 1) patients’ condition (ASA score); 2) the degree of colonic perfusion (ischemia); and 3) per operative bleeding (blood loss> 500cc). These variables should be considered in the
elaboration of future scoring systems to predict outcome of emergency colorectal surgery.
years after resection
1
2
3
4
5
Conclusion: A considerable difference in the dynamics of recurrent disease of colon cancer after curative
resection was found between the development of liver and lung / peritoneal metastases. Compared to the
literature, our overall rates of local and systemic recurrences are comparable to the rates reported in the
literature at 6 and 20%, respectively. These results might be helpful for the planning of palliative oncological treatment and for the general understanding of tumour dynamics in colon cancer.
11.4
Results of emergency Hartmann’s operation for obstructive or perforated left-sided colorectal cancer
P. Charbonnet, P. Gervaz, A. Andres, P. Bucher, Ph. Morel (Genève)
Objective: Up to 15% of colorectal cancer (CRC) patients present with obstructive or perforated tumors,
and require emergency surgery. The Hartmann’s procedure (HP) provides the opportunity to achieve a
potentially curative (R0) resection, while minimizing the surgical trauma in poor-risk patients. The aim of
this study was to assess the surgical (operative mortality), oncological (long-term survival after curative
resection) and functional (permanent colostomy vs. restoration of intestinal continuity) results of emergency HP for obstructive or perforated left-sided CRC.
Methods: A retrospective review of 50 patients who underwent emergency HP for perforated/obstructed
CRC in our institution between 1995 and 2006.
Results: Median age of patients was 75 (range 22-95) years and the indications for HP were obstruction
(32) and perforation (18 patients). Operative mortality and morbidity were 8% and 26% respectively. 35
patients (70%) were operated with a curative intent; in this group, overall 1-, 3- and 5-year survival rates
were 80%, 54% and 40%. In univariate analysis, the presence of lymph node metastases was correlated
with poor 5-year survival (62% [Stage II] vs. 27% [Stage III], log-rank test, p=0.02). Eleven patients (22%)
had their operation reversed with a median delay of 225 (range 94-390) days. In this subgroup, two
patients died from distant metastases, but there was no instance of loco-regional recurrence.
Conclusion: Hartmann’s operation remains a good option to relieve symptoms related to obstructive or
perforated left-sided CRC. It is associated with an acceptable surgical morbidity, as well as oncological
outcome, in a population of compromised patients. Hartmann’s reversal is feasible in a minority of them,
after a prolonged delay, with a null surgical mortality and no loco-regional recurrence.
11.5
Risk factors for postoperative mortality/morbidity after emergency colorectal surgery
K. Skala, P. Gervaz, N.C. Buchs, B. Mugnier-Konrad, Ph. Morel (Genève)
Objective: Thoracic epidural analgesia (TEA) provides superior analgesia with a lower incidence of postoperative ileus when compared with systemic opiate analgesia in open colorectal surgery. However, in
laparoscopic colorectal surgery the role of TEA is not well defined. This prospective observational study
investigates the influence of TEA in laparoscopic colorectal resections.
Methods: All patients undergoing colorectal resection between November 2004 and February 2007 were
assessed for inclusion into a prospective randomized trial investigating the influence of bisacodyl on
postoperative ileus. All patients treated by laparoscopic resection from this collective were eligible for the
present study. Primary endpoints were use of analgesics and visual analogue scale (VAS) pain scores.
Secondary endpoint concerned full gastrointestinal recovery, defined as the mean time to the occurrence
of the following 3 events (GI-3): first flatus passed, first defaecation, first solid food tolerated.
Results: 75 patients underwent laparoscopic colorectal resection, 39 in the TEA group and 36 in the nonTEA group. Patients with TEA required significantly less analgesics (metamizol median 3.0g [0-32g] vs.
13.8g [0-28g], p<0.001; opioids mean 12mg [±2.8 standard error of mean, SEM] vs. 103mg [±18.2
SEM], p<0.001). VAS scores were significantly lower in the TEA group (overall mean 1.67 [±0.2 SEM] vs.
2.58 [±0.2 SEM]; p=0.004). Mean time to gastrointestinal recovery (GI-3) was significantly shorter (2.96
[±0.2 SEM] days vs. 3.81 [±0.3 SEM] days; p=0.025).
Conclusion: TEA in provides a significant benefit in terms of less analgesic consumption, better postoperative pain relief and faster recovery of gastrointestinal function in patients undergoing laparoscopic
colorectal resection.
11.7
MR-defecography: prospective comparison between two different rectal enema compositions
A. Solopova1, F. Hetzer2, B. Marincek1, D. Weishaupt1 (1Zürich, 2St. Gallen)
Objective: To compare two different rectal enemas for MR defecography (MRD) consecutively within the
same individual.
Methods: 20 patients underwent twice MRD using a 0.5T open-configuration system in the sitting position. In the first imaging session, the MRD was performed with a rectal enema consisting of potatoe
starch spiked with gadolinium (PS-Group). In the second session, the enema consisted of ultrasound gel
spiked with gadolinium (US-Group). The imaging protocol for both sessions consisted of images obtained
at rest, at maximal sphincter contraction, at straining and during defecation. All images were analyzed
quantitatively by measuring contrast-to-noise ratio (CNR) and were reviewed in a blinded fashion by three
independent observers with regard to the visibility and the extent of various pelvic floor abnormalities. The
interobserver agreement was determined and the duration of the evacuation phase was measured.
Results: The CNR values between the rectum and the perirectal tissue of the PS-group (167.49±44.4)
were significantly higher than those obtained in the US-group (150.2±37.8) (P<0.05). The visibilities of
the anterior rectoceles and the intussusceptions scored higher in the PS-group compared to the US-group
(mean visibility score in PS-group, 2.8±0.42; mean visibility score in US-group, 2.3±0.77). The size and
the number of incompletely emptying anterior rectoceles were higher in the PS-group. The interobserver
agreement was good to very good for all of the abnormalities visualised with both types of enemas (_values 0.72-0.87). The duration of evacuation was significantly longer for the PS-group (p =0.002).
Conclusion: Both, ultrasound gel and potatoe starch, provide a good contrast and depiction of relevant
pelvic floor abnormalities. However, the visibility and the extent of pelvic floor abnormalities are dependent
on the composition of the inserted rectal enema. In particular, the size and the degree of the anterior
rectocele evacuation as well as the intususception size are often underestimated when using ultrasound
gel for the rectal enema.
Objective: Emergency colorectal resections are difficult procedures, often performed in elderly patients
with associated co-morbid conditions, resulting in prolonged ICU/hospital stay. This study was designed
to identify the risk factors for mortality and morbidity in patients undergoing emergency colorectal surgery.
Methods: All procedures involving emergency colorectal procedures performed in a single institution
31
11.8
Morbidity and functional outcome of Stapled TransAnal Rectal Resection (STARR) with Contour® TranstarTM in Obstructed Defecation Syndrom (ODS)
K. Wolff, L. Marti, J. Lange, F. Hetzer (St. Gallen)
Objective: The stapled transanal rectal resection (STARR procedure) is an effective treatment for obstructed defecation syndrome (ODS) caused by intussusception and rectocele. Recently a new technique
has been developed using the new Contour Transtar stapler, which was specifically designed to facilitate
the STARR procedure We report our first experience with this new technique.
Methods: Patients still suffering from ODS after completed conservative treatment and rectal redundancy
in MR-defecography were included. Data were prospectively collected in a web-based database and included details of preoperative assessment, surgical intervention and postoperative outcome. Functional
outcome was assessed using Longo’s Obstructed Defaecation Syndrome Score (ODS Score), a Symptom Severity Score (SSS), and the Cleveland Clinic Continence Score.
Results: From January to November 2007, 20 consecutive patients (19 female) were enrolled with a
median age of 64 years (range 20-87). Median operation duration was 43 min (30-200) and hospital
stay was 6 days (2-8). The median specimen weight was 27 g (15-53). In one patient an intraoperative
anastomotic dehiscence occurred. At 6 weeks follow-up, the overall morbidity was 40%consisting only
of minor complications (one patient each with self limiting bleed, persistent pain, perianal thrombosis
requiring incision, minor incontinence together with fecal urgency; five patients with minor incontinence).
Neither sepsis, fistula nor deaths were reported. At 6 weeks follow-up the median ODS score and SSS
were significantly lower than pre-operatively (ODS pre-op: 14 (8-18), 6 weeks po: 5 (2-12), P<0.0001,
paired Wilcoxon test. SSS pre-op: 14 (6-21) 6 weeks po: 3 (0-19), P<0.0001). Each patient had lower
scores at the 6 week follow-up than pre-operatively. At the 3 month follow-up (N=19) the median SSS was
further reduced 2 (0-8), P=0.041 compared to 6 weeks po) while the median ODS score did not change
significantly 4 (2-12), P= 0.17). No patient had an increased Continence Score 3 months pre-op: 0 (0-20),
3 months po: 0 (0-5), P=0.012)
Conclusion: Contour Transtar is a safe and effective treatment for ODS with an acceptable morbidity rate.
Comparative studies are needed to fully evaluate its clinical benefit and its preferential use over existing
techniques for STARR.
11.9
Prospective clinical and radiological assessment before and after Stapled Trans Anal Rectal Resection
(STARR) for Obstructed Defecation Syndrome (ODS)
D. Dindo1, K. Lehmann1, D. Weishaupt1, F. Hetzer2, P.-A. Clavien1, D. Hahnloser1 (1Zürich, 2St.Gallen)
common in the LA group (47.7%, vs. GA 20.4%, p < 0.001). Haematomas requiring surgery were more
common in the GA group (6.4% vs. 3.0%, p < 0.02). Peripheral nerve complications were more common
in the GA group 10.7% vs. 4.3%, p < 0.001).
Conclusion: CEA under LA can be performed safely and may lead to better neurological outcome as
compared to GA. Risk factor analysis did not reveal specific risk groups.
13.2
Revascularisation of the external carotid artery in patients presenting ophthalmic ischemia
L. Niclauss, D. Delay, P. Ruchat, L.K. von Segesser (Lausanne)
Objective: Revascularisation of the external carotid artery is rarely performed. Indications include cerebral
ischemia with occluded internal carotid systems, jaw claudication or ophthalmic ischemia. We present
three cases of surgical external carotid reperfusion to treat chronic retinal ischemia.
Methods: Three male patients (mean age 68 years) were operated in 2007. Clinical preoperative course
was characterized by subjective deterioration of visual acuity and episodes of “Amaurosis Fugax” in the
first two patients and diminution of visual acuity with documented papillary ischemic neovascularisation
of both eyes in the third. The first patient was found to have severe stenosis of right internal and external
carotid arteries coupled with occlusion of the ophthalmic artery partially collateralized by the external
carotid system. The second patient had occlusion of both common and internal carotid arteries. The third
patient had occlusion of the left common carotid artery, the left subclavian artery (with subclavian steal
syndrome) and severe stenosis of the left external carotid artery. Surgical treatment consists in an endarterectomy of the bifurcation and the internal carotid artery completed by a patch angioplasty of the external carotid artery in the first patient. An isolated endarterectomy of the external carotid artery, completed
by a subclavian to external carotid artery bypass has been realised in the second patient. The third patient
underwent left external carotid endarterectomy together with common carotid to left subclavian artery
bypass (for subclavian steal syndrome).
Results: All patients were alive and re-examined at one month. The first patient described subjective
amelioration of his visual acuity but presented a postoperative acute ischemic glaucoma. The other two
patients had amelioration of the acuity of vision confirmed by postoperative ophthalmologic exploration.
None of the patients presented neurological complication.
Conclusion: In case of severe arteriosclerosis of the internal carotid arteries and their terminal branches
the external carotid arteries play an important role in providing collateral blood supply to the retina and
brain. In these situations surgical revascularisation of the external carotid artery may be indicated and
can be performed with success.
Objective: The clinical and morphological outcome of patients with obstructed defecation syndrome
(ODS) after Stapled TransAnal Rectal Resection (STARR) was prospectively evaluated.
Methods: 24 consecutive patients (22 female) with median age of 61 years (range 36-74) suffering
from ODS and with rectal redundancy on MR defecography were enrolled in the study. Constipation was
assessed using the Cleveland Constipation Score (CCS). Morphological changes were determined by
closed-configuration MR defecographies before and after STARR. STARR was performed with two PPH-01
staplers in lithothomy position.
Results: After a median follow-up of 18 months (6-36), CCS significantly reduced form 11 (1-23) preoperatively to 5 (1-15) postoperatively (p=0.02). In 15/20 patients, pre-existing intussusception was no
longer seen in MR defecography. Anterior rectoceles were significantly reduced in size, from 30mm to
23mm (p=0.01), whereas the number of detectable rectoceles did not significantly change. Complications occurred in 6 of 24 patients, however, only two were severe (one bleeding and one persisting pain
requiring reintervention).
Conclusion: STARR is a safe and effective treatment for patients with ODS. Clinical improvement correlates well with morphological correction of the rectal redundancy whereas correction of intussusception
seems to be of particular importance in ODS patients.
13.3
13
13.4
Vascular Surgery
13.1
Local versus general anaesthesia for carotid endarterectomy – improving the gold standard?
H. Savolainen1, B. Gahl1, H. Lutz2 (1Bern, 2Giessen/DE)
Objective: Carotid endarterectomy (CEA) reduces stroke risk among patients with symptomatic 70-99%
carotid artery stenosis. To achieve this, low operative risk is crucial. However, it may depend on whether
local or general anaesthesia is used. The aim of our study was to assess the risks of CEA under LA compared with that under GA. Primary endpoint was neurological outcome.
Methods: Retrospective study, prospective data bank. Detailed analysis of hospital charts of 1341 consecutive carotid endarterectomies between January 1995 and December 2004. The patients were divided
into two groups according to intraoperative anaesthesia (local, LA, 465 patients or general, GA, 876 patients). Patients in the LA group were older (68.5 vs. 66.5 years, p < 0.001). There were more diabetic patients in the LA group (35.2% vs. 23.2%, p < 0.001) as well as those with hypertension (88.1% vs. 79.7%,
p < 0.01). In the GA group, 554 (63.2%) patients were symptomatic, in the LA group 227 (48.6%) (p <
0.001). There were 6 (1.3%) conversions to GA. Statistical analysis: Univariate analysis and backward
stepwise logistic regression analysis were performed.
Results: Mortality was 0.5% (LA) vs. 0.8% (GA). Cerebral complications (transient attacks and stroke
combined) were more common in the GA group (6.9% vs. 3.4%, p < 0.009). Combined morbidity (stroke
alone) and mortality were not different (4.1% vs. 3.2%). Postoperative hypertension episodes were more
32
Risk-based approach in the management of coincidental extra- and intracranial aneurysms
R. Feer1, B. Marty2, P. Ruchat2, M. Menth1, J. Michel1, B. Egger1 (1Fribourg, 2Lausanne)
Objective: To demonstrate the use of risk-based approach in the management of coincidental aneurysms
in terms of priority and modality of treatment.
Methods: Case report: Investigation of a pulsatile mass in a 60 year old woman with an uneventful history
revealed a 2 cm saccular aneurysm of the left internal carotid artery, and two saccular aneurysms of the
medial cerebral artery, 7mm diameter on the right and 3.7mm on the left side. Priority was given to the
larger right-sided intracranial aneurysm treated by open clipping. In a second stage successful resection
and end-to-end anastomosis of the left carotid aneurysm was performed under local anesthesia and
careful blood pressure monitoring. Endovascular coiling of the left-sided intracranial aneurysm was scheduled six months later.
Results: The staged procedures of this aneurysms were successful. The postoperative courses were
without adverse event.
Conclusion: The order of treatment is crucial and focused on avoiding cerebral hypertension. Therefore
the clipping of the cerebral aneurysm is given precedence. The presence of sequential aneurysms of the
carotid axis requires balancing open versus endovascular interventions to minimize the risk.
L’échec très précoce des fistules radio-céphaliques peut-il être prédit par la mesure du débit peropératoire?
F. Saucy, C. Haller, E. Haesler, S. Déglise, H. Probst, J. Corpataux (Lausanne)
Objective: L‘échec précoce des fistules radio-céphaliques durant les premiers jours postopératoires est
rare mais nécessite souvent la confection d‘un nouvel accès. Le bilan préopératoire ainsi que la surveillance postopératoire rapprochée ne permettent pas d‘éviter l‘occlusion et la non maturation. La mesure
de débits peropératoires pourrait évaluer le risque d‘échec très précoce et ainsi induire un changement de
stratégie chirurgicale dans le même temps opératoire.
Methods: De janvier 2004 à décembre 2006, nous avons réalisé la mesure systématique des débits
peropératoires des fistules radiocéphaliques primaires chez 58 patients au moyen d‘une sonde ultrasonographique utilisant le principe de temps de transit (Medistim, Norvège, Oslo). Le groupe 1 est représenté par des patients dont la fistule présente un débit supérieur à 100ml/min tandis que le groupe 2
présente des débits inférieurs à 100 ml/min.Chaque évènement relatif à l‘accès vasculaire a été reporté
de manière prospective ainsi que la mesure du débit postopératoire à 1 mois.
Results: Dans le groupe 1, le débit moyen peropératoire est de 271ml±186ml/min et de 767ml±290ml/
min à un mois postopératoire alors que dans le groupe 2, il est de 62±25ml/min et de 593±291ml/min
respectivement. Un débit inférieur à 100ml/min est mesuré chez 33% des patients. Parmi ces patients,
31% ont présenté une occlusion très précoce (<7 jours) ayant nécessité la confection d‘un nouvel accès.
Dans le groupe 1, seul 5% des accès vasculaires se sont occlus précocement (p=0.01). La non maturation a été observée chez 3 patients dont seul un patient appartenait au groupe 2.
Conclusion: La mesure peropératoire d‘un débit inférieur à 100ml/min lors de la confection d‘une fistule
radiocéphalique indique un risque élevé d‘occlusion très précoce. La décision durant l‘intervention de
conserver la fistule en l‘état ou de la modifier immédiatement doit être prise en fonction du capital artérioveineux à disposition ainsi que les caractéristiques intrinsèques du patient.
13.5
RapidaxTN is a new self-sealing PTFE hemodialysis access graft: review of initial clinical experiences
R. von Allmen, F. Dick, H. Savolainen, I. Schwegler, J. Schmidli, M.K. Widmer (Bern)
Objective: RapidaxTN represents a new generation of PTFE hemodialysis access grafts with self-sealing
properties. Immediate possibility of puncture is thought to be its most promising feature. Aim was to assess actual time to first use and to determine indication and outcome of the first implanted RapidaxTN
grafts in clinical use.
Methods: Outcome analysis of a consecutive series of 19 RapidaxTN grafts which were implanted to
18 patients with renal failure between November 2005 and November 2007. Median follow-up was 9
(4-25) months. Median patient age was 69 (29-88) years, and eleven patients were of female gender.
Main study endpoints were indications for implantation, time to first hemodialysis via RapidaxTN and rate
of reinterventions.
Results: In eleven cases, RapidaxTN was implanted for native fistula failure, and in six cases for prosthetic
access graft failure. In two patients, RapidaxTN was implanted as primary hemodialysis access. Overall,
RapidaxTN was implanted only preparatively for preterminal renal failure in three patients, and for ongoing
dialysis in fifteen patients. Of these, seven underwent bridging hemodialyis via insertion of a temporary
central venous catheter. In nine patients, however, short-time bridging hemodialysis was achieved by repetitive single needle catheterizations. Median duration until first RapidaxTN puncture was 9 days (1-26).
Seven patients underwent reinterventions during follow-up: six due to graft occlusions, and one because
of puncture associated hemorrhage.
Conclusion: The RapidaxTN hemodialysis access graft can safely be used for early hemodialysis after implantation with acceptable intermediate-term reintervention rates. Insertion of central venous catheters for
bridging dialysis seems to be needed less often. However, the convenience of the self-sealing properties is
not routinely taken advantage of in clinical use yet.
13.6
Ist die venöse Portimplantation in Allgemeinnarkose im Hinblick auf ein modernes OP-Management
noch zeitgemäss?
J. Schuld, S. Richter, M.K. Bolli, M.K. Schilling (Homburg/DE)
Objective: Der Gebrauch venöser Portsysteme stellt für Patienten insbesondere im Hinblick auf eine
Chemotherapie oder parenterale Ernährung eine angenehme Alternative zu wiederholten peripher- oder
zentralvenösen Katheterisierungen dar. Trotz des zunehmenden Anteils der interventionell ambulant implantierten Systeme, stellt die offen chirurgische Implantation eine sichere und komplikationsarme Alternative dar. Es stellt sich die Frage, ob vor dem Hintergrund des wachsenden gesundheitsökonomischen
Druckes, die offene Implantation in Allgemeinnarkose noch zeitgemäß erscheint.
Methods: In einer retrospektiven Analyse wurden alle Portimplantationen der Jahre 2001–2007 im Hinblick auf OP-Zeiten und intraoperative Daten ausgewertet. Der Schwerpunkt der Datenauswertung lag in
den unmittelbar an die Operation gekoppelten Zeiten, wie der Operationsdauer, der Gesamtdauer der OP
sowie der Zeit bis zur Ausschleusung. Verglichen wurden hierbei Portimplantationen in Lokalanästhesie
(LA) und Allgemeinnarkose (ITN).
Results: Die Operationsdauer war in beiden untersuchten Gruppen nicht unterschiedlich (LA 47,27±1,40
min vs. ITN 45,41±0,75 min, p=0,244). Patienten, bei denen der Port in LA implantiert wurde, hatten eine
signifikant kürzere Aufenthaltsdauer im Operationstrakt (LA 95,9±1,78 min vs. ITN 105,92±0,92 min,
p<0,001). Dies basiert auf den signifikant kürzeren Zeiten bei Einschleusung inlcusive der Narkoseeinleitung (LA 39,57±0,69 min vs. ITN 50,46±0,52 min, p<0,001) und bei der Ausschleusung aus dem
Operationssaal (LA 9,06±0,23 min vs. 10,14±0,17 min, p<0,001). Der intraoperative Blutverlust sowie
die Durchleuchtungsdauer- und Dosis unterschieden sich in beiden Gruppen nicht.
Conclusion: Die Ergebnisse zeigen, dass eine Implantation von venösen Portsystemen in Lokalanästhesie der Implantation in Allgemeinnarkose im Hinblick auf die unmittelbar von der Operation abhängenden
Zeiten im Operationstrakt deutlich überlegen ist. Bei gleicher Operationsdauer, gleichem materiellen Aufwand und niedrigerem Personalbedarf stellt die Portimplantation in Lokalanästhesie die Methode der
Wahl dar und ermöglicht schnellere Wechselzeiten. Die Allgemeinnarkose für Portimplantationen solle
nur noch in Ausnahmefällen durchgeführt werden.
Thoracic Surgery
15
groups according to their initial ventilation support requirements: no ventilation support, NIPPV or mechanical ventilation. Survival and ICU stay were compared for each group using Fisher’s exact test.
Results: Of the 82 patients admitted to the ICU following thoracic surgery, 52 did not require ventilation
support, 15 were initially managed by NIPPV and 15 were admitted intubated following surgery. Survival was comparable in non ventilated (52 of 52 patients, 100%), NIPPV (12 of 15 patients, 80%) and
intubated groups (14 of 15 patients, 93%, NS). Three patients of the NIPPV group required mechanical
ventilation and had a significantly decreased survival compared to the other groups (1 of 3 patients, 33%,
p<0.05). ICU stay was significantly greater in the NIPPV (median 4 days) and intubated (median 5 days)
groups compared to the non ventilated group (median 1 day).
Conclusion: Patients admitted with respiratory insufficiency have longer ICU stays but their survival is not
affected. NIPPV is the first line therapy for patients developing respiratory failure after thoracic surgery;
however, mechanical ventilation should not be delayed in case of treatment failure. Patients that require
mechanical ventilation following NIPPV have a bad prognosis.
15.2
Surgical treatment of postintubation membranous tracheal rupture
G.L. Carboni, J.R. Küster, J. Nicolet, P. Dumont, A.E. Dutly, R.A. Schmid (Bern)
Objective: Tracheobronchial laceration is a rare complication after intubation. A recent case treated in
our institution induced us to review the pertinent literature regarding airway management and surgical
options in approaching this difficult clinical problem.
Methods: We describe a case of a 54-year-old female patient sustaining a 6 cm longitudinal laceration of the membranous part of the trachea following emergency intubation on scene by an emergency
physician because of severe respiratory insufficiency in exacerbating COPD. After diagnosis the patient
was referred to our institution where she received surgical treatment. We discuss current approaches in
airway management and surgical treatment of this rare iatrogenic injury in the light of the most recently
published data.
Results: Airway management should be tailored to the extent and localization of the injury. Cervical lesions can usually easily be bridged by fiber optic endotracheal intubation. Whereas obtaining airway
control in more distal lesions can be challenging. Positioning of the endotracheal tube must always be
controlled endoscopically. Surgical management is indicated for larger lesions. Access to trachea can be
achieved from a cervical incision in high lesions. For ruptures of the distal trachea including carina and
right main bronchus right posterolateral thoracotomy provides the best access. Generous drainage and
antibiotic therapy are mandatory. Pediculated muscle flaps can provide viable tissue in difficult situations
with large contaminated lacerations
Conclusion: Early recognition of tracheal injury after intubation is important to avoid devastating infectious
complications. Surgical treatment is mandatory for larger lesions of the distal trachea, carina and main
bronchi. Airway management is difficult and requires a well-trained team.
15.3
Closure of large esophageal dehiscence after surgery or esophageal perforations associated with mediastinal sepsis by use of pedicled muscle flaps
N. Kotzampassakis, M. Christodoulou, H. Vuilleumier, G. Dorta, H. Ris (Lausanne)
Objective: Large esophageal dehiscence after esophageal resection and reconstruction surgery or esophageal perforation with delayed (>72h) diagnosis represent a life-threatening therapeutic dilemma.
Primary esophageal repair is prone to fail in the context of mediastinal sepsis, and esophageal exclusion
may be disproportionate procedures in critically ill patients. We repaired large intrathoracic esophageal
perforations or dehiscence associated with mediastinal sepsis by suturing pedicled muscle flaps into the
esophageal defect without attempting a primary repair.
Methods: Eight patients underwent esophageal repair by pedicled muscle flaps. All patients presented
with delayed diagnosis, mediastinal sepsis and empyema. Five patients presented with large esophageal
dehiscence after bariatric surgery or esophageal resection and reconstruction and three with esophageal
perforations. The length of the esophageal defect ranged from 3 to 12 cm. Closure was performed by a
full thickness diaphragmatic muscle flap (4) or an intrathoracically transferred pedicled latissimus dorsi
(1), serratus anterior (2) or pectoralis major (1) muscle flap. All patients had postoperative Gastrografin®
transit assessment and esophagoscopy 6 months after discharge.
Results: There was no postoperative 90d mortality. One patient died after medical intoxication 4 months
and one after gastrointestinal bleeding 12 months after the operation. During follow-up ranging from 3 to
36 months, five patients had an uneventful restoration of the esophageal continuity. Two patients required
temporary stenting and one repeated dilatation with restoration of esophageal functionality.
Conclusion: Large esophageal dehiscence after surgery or esophageal perforations in the context of mediastinitis can be safely closed by full thickness pedicled muscle flaps without attempting a primary repair.
This technique allows restoration of esophageal continuity with good functional results while avoiding
esophageal exclusion and secondary reconstruction.
15.1
15.4
Management of respiratory insufficiency following thoracic surgery: outcome in patients with invasive
and non-invasive ventilations
J.Y. Perentes, J. Revelly, H. Ris (Lausanne)
Indikation zur anatomischen Resektion und Lymphknotendissektion bei ACTH-sezernierendem Lungentumor
A. Freitas, R. Kuster, W. Nagel (St. Gallen)
Objective: Non invasive positive pressure ventilation (NIPPV) has become the first line treatment of respiratory insufficiency. However, little is known on its use on patients with respiratory insufficiency following
thoracic surgery and admitted to the intensive care unit (ICU). Here we determined how the initial ventilation support requirements affect survival and ICU stay of these patients.
Methods: The medical records of the 82 consecutive patients undergoing thoracic surgery and admitted to the ICU between January 2005 and June 2006 were reviewed. Patients were clustered into three
Objective: Nach dem histologischen Nachweis eines ACTH-sezernierenden malignen Karzinoids via
thorakoskopische Lungen-Wedgeresektion wird die Indikation zur anatomischen Lungenresektion mit
mediastinaler Lymphadenektomie diskutiert.
Methods: Case report.
Results: Ein 29 jähriger Patient mit den klassischen Symptomen eines zentralen Morbus Cushing hatte
eine unauffällige craniocerebrale Magnetresonanztomographie, hingegen in der thorakoabdominopel-
33
vinen Computertomographie einen pulmonalen Rundherd links apikal. Die histologische Aufarbeitung
nach der thorakoskopischen Lungen-Wedgeresektion zeigte einen malignen Karzinoidtumor im Bereiche
eines kleinen Bronchus (1,5x1,4x0,6 cm) mit einem minimalen Tumorabstand zum Resektionsrand von
0,5 cm, die ACTH-Produktion konnte immun-histiochemisch nachgewiesen werden. Bei nur partiell regredienter Cushing- Symptomatik wurde drei Monate später eine anatomische Lungen-Oberlappenresektion
und mediastinale Lymphadenektomie durchgeführt. Zwei von 12 peribonchialen N1-Lymphknoten hatten
einen Tumorbefall. Im weiteren Verlauf trat eine vollständige endokrine Normalisierung ein, bisher kein
Tumorrezidiv.
Conclusion: Trotz R0-Resektion des ACTH-sezerniereden Lungentumors persisterte die Cushing-Symptomatik. Der Tumorbefall von 2 N1-Lymphknoten nach der anatomischen Nachresektion bestätigte die
Indikation zur Folgeoperation sowohl aus endokriner als auch tumorbiologischer Sicht.
15.5
Minimal invasive Parathyroidektomie: Lokalisationsdiagnostik, Operationstechnik und intraoperative
Hormonbestimmung
M. Grillet, K. Daniel, P. Villiger, M. Furrer (Chur)
Objective: Die gezielte minimal invasive Adenomentfernung beim primären Hyperparathyreoidismus
(pHT) macht eine präzise präoperative Lokalisationsdiagnostik und eine intraoperative Erfolgskontrolle
zur unabdingbaren Voraussetzung. Dies wurde anhand einer prospektiven Studie untersucht, wobei
gleichzeitig die Effizienz der neuen Operationsmethode überprüft wurde.
Methods: Über einen Zeitraum von gut einem Jahr wurden in einer konsekutiven Serie 10 Patienten mit
pHT eingeschlossen. In allen Fällen wurden eine präoperative NSD-Szintigraphie und eine MRI-Untersuchung des Halses durchgeführt. Die Parathormon (PTH) - Bestimmung erfolgte präoperativ und 10 Min.
nach Adenom-Entfernung. Bei fehlendem 50%igen Abfall des PTHs sah der Algorhythmus vor, die Bestimmung nach 30 Min. zu wiederholen und in jedem Falle eine Schnellschnitt-Untersuchung durchzuführen.
Im Bereiche der anhand der MRI-Untersuchung ausgemessenen Lage des Adenoms erfolgte eine quere
3-4 cm lange Inzision in der Hautspaltlinie mit Durchtrennung des Platysmas und longitudinaler Spaltung
der geraden Halsmuskulatur zur direkten Exploration.
Results: Die szintigraphische Lokalisation war in allen Fällen korrekt. Für den Radiologen war die Szintigraphie in 2 Fällen die entscheidende Hilfe für die korrekte MRI-Befundung. Bei allen in dieser Studie
operierten Patienten konnte ein Nebenschilddrüsenadenom entfernt werden. Alle Patienten zeigten intraoperativ einen PTH Abfall von über 50%, die mittlere Operationszeit betrug 44 minuten.
Conclusion: Die präzise präoperative Lokalisationsdiagnostik mittels Szintigraphie und MRI war bei unseren präliminären Erfahrungen immer korrekt und ermöglichte in jedem Falle ein Auffinden und Entfernen
eines Adenoms innert kurzer Zeit über einen minimalen Zugang. Die intraoperative Hormonbestimmung
stellt eine wertvolle Erfolgskontrolle dar.
15.6
Indication and complications of VATS and open lung biopsy in immunocompromised patients with pulmonary infiltrates
F. Gambazzi, D. Stolz, L. Bubendorf, A. Gratwohl, D. Lardinois, M. Tamm (Basel)
Objective: Infectious and non-infectious pulmonary complications are frequent in immunocompromised
patients with pulmonary infiltrates. Empiric antibiotic therapy is often given. If there is antibiotic resistant
fever or persistent infiltrates further diagnostic steps are often needed. Bronchoscopy with bronchoalveolar lavage allows to detect micro-organisms. The assessment of BAL neutrophils, serum procalcitonin and
C-reactive protein is helpful to diagnose bacterial infection even if patients are pretreated with antibiotics
(Stolz et al. Chest 2007; 132: 504-514). However in a considerable number of cases VATS or open lung
biopsy (OLB) is needed to achieve a definitive diagnosis and to initiate adequate treatment.
Methods: We assessed the diagnostic yield and complication rate in 85 immunocompromised patients
undergoing diagnostic surgery over a seven year period (2000-2007). Underlying diseases of these patients consisted of 56 hematologic malignancy, 11 rheumatologic diseases, 5 solid organ transplantation
and 3 patients with solid malignant tumors.
Results: 55 patients underwent VATS biopsy and 30 open lung biopsy. Histological diagnoses revealed:
17 interstitial pneumopathies without infection, 16 bronchiolitis obliterans, 5 diffuse alveolar damages, 1
echinococcus, 3 solid tumors (lymphoma; melanoma; hemangioma), 4 infectious bronchiolitis, 20 invasive fungal infections and 8 other infections (2 pneumocystis, 3 tuberculosis, 1 atypical mycobacteriosis;
1 pseudomonas, 1 enterobacter). In 3 cases a histological confirmation was not possible. Based on
the histological results of VATS or OLB the therapeutic regimen was changed in 75 patients. There was
no perioperative death. A prolonged ICU stay (>72h) was needed in a total of 17 cases. Ten of these 17
patients were already on the ICU when a surgical biopsy was taken. Overall 30 day mortality was 7.7 %
(9/85) (4 diffuse alveolar damage; 2 vasculitis; 1 enterobacter pneumonia with ARDS; 1 multi organ
failure fibrosing alveolitis; 1 invasive fungal infection). Five of the 9 deaths occurred in patients already ventilated prior to surgery. Three of the 4 patients who died within 30 days but have not been ventilated prior
to surgery revealed a diagnosis of diffuse alveolar damage. Wound infection was observed in 2 patients.
A prolonged air leak needing drainage for more than 3 days occurred in 32 %. There were no differences
in complication rates if VATS or OLB has been performed.
Conclusion: Summary and Conclusion: VATS and OLB have a high diagnostic yield in immunocompromised patients with pulmonary complications where bronchoscopy with bronchoalveolar lavage is
non diagnostic. Perioperative surgical complications occur rarely except for the need for prolonged tube
drainage. 30 day survival of patients was good except for patients already ventilated prior to surgery or
suffering from diffuse alveolar damage.
34
15.7
Postoperative complications of hematologic patients undergoing lung resection for suspected invasive
pulmonary aspergillosis
F. Gambazzi1, P. Matt1, J. Habicht2, J. Halter1, D. Heim1, A. Buser1, A. Gratwohl1, D. Lardinois1,
M. Tamm1 (1Basel, 2Aarau)
Objective: Pulmonary complications are frequent in patients with hematologic malignancies undergoing
high dose chemotherapy and autologous or allogeneic stem cell transplantation. Invasive pulmonary
aspergillosis is one of the most feared infectious complications. With the introduction of voriconazole
and other new antifungal agents (Herbrecht N Engl J Med 2002; 347: 408-415) mortality has dropped
from 50-80% to around 30%. However there are still cases we consider lung resection the best option
to diagnose and treat invasive pulmonary aspergillosis (Reichenberger et al. Eur Respir J 2002; 19: 13). Furthermore histology and culture of surgically resected lung tissue occasionally reveals other fungi
than aspergillus or other pathogens including mucormycosis, candida, hormographiella aspergillata and
atypical mycobacteria as observed in our series. However the decision to perform lung resection in these
high risk patients needs to be carefully assessed.
Methods: We therefore analysed postoperative complications in a total of 60 patients (between 1983 and
2007) undergoing lung resection for suspected or proven invasive pulmonary aspergillosis.
Results: 42 patients suffered from leukaemia, 4 from myelodysplastic syndrome, 7 from aplastic anemia, 5 from lymphoma, 1 from melanoma and 1 from multiple myeloma. 38 patients underwent high
dose chemotherapy, 16 stem cell transplantation and 6 antilymphocyte globuline therapy. On the day
of surgery 34 patients were neutropenic. Mean platelet count was 83 x 109/L. Lung resection consisted
of lobectomy in 23, wedge resection in 35 and enucleation in 2 cases. Persistent fungal infection could
be documented in the resected lung tissue in 42 patients (70%). Major postoperative complications occurred in 4 patients (pleural aspergillosis; reoperation for bronchial stump dehiscence; ARDS; laparotomy
for liver bleeding due to preoperative CT guided puncture). Overall mortality at 30 days was 10% (6 of
60 patients). Two persistent neutropenic patients died with disseminated invasive pulmonary aspergillosis, two patients with bacterial septicaemia and two patients with respiratory insufficiency. Medium and
longterm survival was mainly influenced by progression or reoccurrence of the underlying hematologic
disease and neither by the surgical procedure nor by unsuccessful resection of the fungus.
Conclusion: Despite a severely immuno-compromised status lung resection for invasive pulmonary aspergillosis in patients with hematologic diseases is associated with an acceptable risk of postoperative
complications.
15.8
Follow-up strategies in soft tissue sarcoma for early diagnosis of pulmonary metastases
Y. Acklin, G. Gadient, R. von Moos, M. Furrer (Chur)
Objective: The follow up strategies of potentially curative resected soft tissue sarcoma (STS) are very
inconsistent. Several surveillance programs are available but no standardized guidelines exist. Our objective was to evaluate the time until occurrence of pulmonary metastases and the effectiveness of our
follow-up practice to detect pulmonary metastases.
Methods: We retrospectively analyzed all cases with STS treated at our department of surgery between
February 1997 and May 2007. Our concept implied observation of the patients after 3 months and every
6 months thereafter. The follow-up practice consisted of clinical examination, imaging of the primary site
by MRI and pulmonary CT scan to exclude eventual metastasis.
Results: From 51 surgically treated sarcoma patients, 43 had a STS (24 trunk, 19 extremity) and were
included. All patients were evaluated. The mean follow-up time was 30 months (3-119). The primary site
tumor were classified according to the FNCLCC grading system. There were 8 G I, 9 G II and 26 G III
tumors. Pulmonary metastasis occurred in 15 from 43 patients (35%). In pulmonary metastasis 6 were
trunk and 9 extremity sarcoma. 4 metastasis originated from initially grad I tumor, 6 from grad II tumors
and 5 grade III tumors. The mean time until occurrence of pulmonary metastasis varied between 0-92
months; mean 13 months. In 7 patients all pulmonary metastasis (47%) could be resected.
Conclusion: The correct follow-up strategy for early diagnosis of pulmonary metastases in soft tissue
sarcoma remains difficult. Our patients show a broad time spectrum of appearance of pulmonary metastases. Frequent and long time follow-up for these patients is crucial, independent from the FNCLCC
grading and the site of the primary tumor.
15.9
In-vivo assessment of angiogenesis and microcirculation in human mesothelioma xenografts
T. Krueger, E. Debefve, C. Cheng, S. Schäfer, J. Ballini, H. van den Bergh, H.B. Ris (Lausanne)
Objective: We describe a rodent model for studying angiogenesis and microcirculation in human mesothelioma xenografts in-vivo.
Methods: Mesothelioma angiogenesis and microcirculation were analysed by intravital microscopy (IVM)
using a transparent chamber preparation in Swiss nude mice (female, age 10-15 weeks). The human
mesothelioma cell line H-meso-1 was used. Two days after implantation of a titanium chamber into the
dorsal skin fold of a nude mouse a 1mm3 fragment of a subcutaneously grown H-meso-1 tumour was
transplanted in the skin fold preparation (n=6). Control animals had chamber preparation but no tumour
implantation (n=5). Angiogenesis, microcirculation and growth of the xenograft were observed up to 10
days after tumour implantation by daily IVM (transillumination and fluorescence microscopy using fluorescein isothiocyanate-dextran).
Results: The take rate of the human mesothelioma xenograft H-meso-1 in the skin fold chamber of nude
mice was 100%. Three days after tumour implantation capillary sprouting was observed in the tumour
periphery in 6 of 6 animals. From day 3 to 10 progressive formation of irregularly shaped capillaries occurred, presenting an inhomogeneous blood flow. Six to 10 days after tumour grafting these newly formed vessels developed anastomoses, and blood flow became more regular throughout the tumour. The
tumour size did not increase significantly during the observation period.
Conclusion: Implantation of H-Meso-1 tumours in the skin fold chamber preparation in nude mice allows
for in-vivo assessment of tumour angiogenesis and microcirculation. This model may serve as a tool for
studying new vascular mediated treatment strategies against malignant pleural mesothelioma.
15.10
Delayed pulmonary graft function: the role of CD26/DPP IV
W. Jungraithmayr1, W. Zhai1, I. De Meester2, M. Cardell1, K. Augustyns2, S. Hillinger1, S. Arni1, S. Scharpe2,
S. Korom1, W. Weder1 (1Zürich, 2Antwerp/BE)
Objective: Systemic inhibition of CD26/DPP IV enzymatic activity has abrogated graft rejection in rat cardiac and pulmonary transplantation models. Organ-specific catalytic inhibition of lung explants prior to
implantation markedly decreased ischemia/reperfusion injury and preserved pulmonary function at 2
hours post-perfusion. Here we investigate the influence of organ-specific inhibitor-preconditioning on the
long-term course of delayed pulmonary graft function due to extended ischemia.
Methods: A syngeneic rat (LEW) orthotopic left lung transplantation model was employed (n=5-6/
group). As inhibitor served AB192 (bis(4-acetamidophenyl) 1-(S)-prolylpyrrolidine-2(R,S)-phosphonate).
Donor lungs in group I and II (controls) were flushed and preserved in Perfadex® for 18h at 4ºC, then
transplanted and harvested after 24-h (II) or 7d (I). Group IV, V and VI grafts were perfused/stored in
Perfadex®+25µmol/L AB192 for 18h at 4ºC, and harvested at 24-h (IV), d3 (V) and d7 (VI). Lungs in
group III were treated as controls (I, II), but received in addition the antioxidant melatonin, harvested after
7d. Primary endpoint was survival. Secondary endpoints (at harvest), included blood gas analysis, peak
airway pressure (PAwP), wet/dry (W/D) weight ratio, myeloperoxidase activity (MPO) and thiobarbituric
acid reactive substances (TBARS).
Results: Survival was significantly better between groups VI (80%) vs. III (40%) and I (16.3%) (p<0.01)
at 7d. At 24h, pulmonary function was significantly superior in group-IV- vs. group-II-grafts: pO2 was
78.7±7.1 vs. 29.8±5.7mmHg (p<0.01); PAwP was 19.3±1.1 vs. 24.3±2.9mmHg (p<0.01); W/D ratio
was 6.7±1.3 vs. 9.5±1.5 (p<0.05); TBARS was 1.1±0.6 vs. 2.5±0.7µM (p<0.05). AB192-preconditioned
grafts (IV, V, VI) continuously improved following implantation, reaching near-baseline measurements at
the d7-timepoint.
Conclusion: Pulmonary perfusion with a novel specific inhibitor (AB192) of CD26/DPP IV enzymatic activity significantly reduces extent and mortality of delayed lung graft function and accelerates recovery
after extended ischemia.
Total TEA - Conventional TEA - Eversional TEA Patch Shunt Interponat Neuromonitoring (SEP) Intraoperative Angiography* Total 579 570 (98%) 9 (2%) 555 (96%) 171 (30%) 10 (2%) 488 (84%) 172 (30%) 2007 102 102 (100%) 0 (0%) 99 (97%) 16 (16%) 3 (3%) 101 (99%) 49 (48%) 2002-2006
477
468 (98%)
9 (2%)
456 (95%)
155 (32%)
7 (1.5%)
387 (81%)
123 (26%)
* In 2% of the performed angiographies a pathologic feature was detected with correction in the same
operative procedure.
Neurological deficits - severe/major - minor - permanent - transient Haemorrhage Cerebral nerve injuries ** Total 20 (3.4%) 8 (1.4%) 12 (2%) 10 (1.7%) 10 (1.7%) 31 (5.4%) 39 (6.7%) 2007 2 (2%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) 4 (4%) 0 (0%) 2002-2006
18 (3.8%)
7 (1.5%)
11 (2.3%)
9 (1.9%)
9 (1.9%)
27 (5.6%)
39 (8.2%)
** Postoperative follow up was performed in 35 (95%). In 6 patients permanent lesions were found. In 29
patients the diagnosed lesion was transient.
Conclusion: CEA under general anaesthesia and the selective use of carotid shunting during CEA requires
an intraoperative monitoring technique. Based on our data and literature findings, SEP-monitoring is a reliable method to prevent neuro-vascular deficits and effectively minimizes shunting frequency. According to
consistent neurological examination in every patient no cerebral nerve injury was missed. It is remarkable
that most of the cerebral nerve injuries were transient. The rate of hemorrhagic complications is higher
than in literature findings because all our patients are operated under ASS and/or Plavix to prevent further
neurological deficits. Intraoperative angiography is a save method for documentation, but had no effect
on reduction of the postoperative neurological deficit.
16.3
Vascular Surgery
16
16.1
Acute innominate arterial bleeding after removal of a percutaneously introduced tracheostomy-cannula
Y. Acklin, M. Furrer (Chur)
Objective: The tracheo-innominate artery fistula (TIF) is a rare midterm complication after percutaneous
dilatational tracheostomy. Without operation, mortality is nearly 100% due to massive tracheal hemorrhage.
Methods: We describe one case with a brief review of the literature.
Results: A 60y-old female sustained a severe traumatic brain injury. In expectance of prolonged intubation, a percutaneous dilatational tracheostomy was performed. The patient was successfully weaned from
the ventilator and the dilatational tracheostomy was to be converted into an epithelialised tracheotomy.
During the process of cannula changement, massive bleeding occurred. A sternotomy and exposure of
the aorta and innominate artery was performed. Continous irritation of the cannula to the pulsative back
wall of the artery might have created the lesion, so far covered by the cannula itself but breaking down
during removal of the cannula. The defect could be excised and the innominate artery reanastomised.
Conclusion: The knowledge of the possibility of a TIF might modify the puncture site at the anterior tracheal
wall when performing percutaneous dilatation tracheostomy. In case of acute hemorrhage beyond 48h
after tracheotomy, a TIF should be considered and immediate surgical intervention is crucial to avoid
fatality.
16.2
A 6-year quality control assessment in carotid surgery
S.A. Bischofberger, R. Kuster, W. Nagel (St. Gallen)
Objective: Since January 2002 all patients undergoing carotid endarterectomy (CEA) were operated
under general anaesthesia, selective shunting and intraoperative monitoring technique by registering somatosensory evoked potentials (SEPs) by stimulating the median nerve. We publish an annually quality
report to improve our quality of treatment.
Methods: From 2002 to 2007, 579 consecutive patients underwent CEA under general anaesthesia and
SEP monitoring. Preoperative neurological assessment, duplex sonography and MR-angiography were
performed. Intraoperative data was recorded. Postoperative neurological deficits, cranial nerve lesions,
secondary haemorrhage and general complications were analysed. Postoperative neurological examination and duplex sonography was performed.
Results: A total of 579 Patients underwent CEA between 2002 & 2007.
Hybridoperation bei suprarenalem Aortenaneurysma: offenes reno-viszerales Debranching und EVAR
M. Vidovic, R. Kuster, W. Nagel (St. Gallen)
Objective: Seit Anfang der neunziger Jahre ist die Technik der endovasuklären Aortenaneurysma-sanierung möglich. Seither erfuhr diese Operationstechnik eine enorme technische Weiterentwicklung. In
diesem Fallbericht beschreiben wir eine Hybridoperation zur Sanierung eines thorakoabdmonellen Aortenaneurysmas bei einem polymorbiden Patienten.
Methods: Case report
Results: Fallbericht: Ein 63-jähriger Patient wurde notfallmässig mit hypertensiver Entgleisung hospitalisiert. Vorbestehend waren eine arterielle Hypertonie mit hypertensiver Herzkrankheit, eine cerebrovaskuläre Insuffizienz mit rezidivierenden cerebrovaskulären Ereignissen, eine chronische Niereninsuffizienz mit
neu entdeckter Nierenarterienstenose rechts, sowie ein regelmässig kontrolliertes thorakoabdominelles
Aortenaneurysma mit St. n. abdominaler aortobifemoralerY-Prothese bei infrarenalem aortoiliakalem Aneurysma vor 16 Jahren und Resektion eines Anastomosen-Aneurysmas inguinal rechts vor 2 Jahren. Das
thorakoabdominelle Aortenaneurysma zeigte eine Grössenprogredienz von 4.7 auf 6.2 cm während den
letzten zehn Wochen. Wegen der ausgeprägten Komorbidität und der abdominellen Voroperation erfolgte
das renoviszerale Debranching mit bilateralen iliakoviszeralen und iliacorenalen Interponaten. Eine Woche später konnte erfolgreich die endovaskuläre Aneurysmaausschaltung von iliakal rechts durchgeführt
werden. Der Heilungsverlauf war problemlos. Bildgebend normale Perfusion aller viszeralen Organe ohne
Anastomosenstenosen.
Conclusion: Bis anhin waren die Möglichkeiten der endovaskulären Aneurysmasanierung wegen Einbeziehung wichtiger arterieller Äste ins Aortenaneurysma beziehungsweise Prothesenverankerung begrenzt. Die neu eingeführten Hybrid-Eingriffe erweitern die Einsatzmöglichkeiten. In einem ersten Eingriff
können Aortenäste auf eine alternative Einflussposition transferiert werden, in einem zweiten Eingriff kann
die eigentliche endovaskuläre Aneurysmaausschaltung (EVAR) durchgeführt werden.
16.4
Failure of contralateral leg cannulation in EVAR – case report of an unconventional solution
S. Meili1, R. Bühlmann1, L. Gürke2, P. Stierli1 (1Aarau, 2Basel)
Objective: Endovascular aneurysm repair (EVAR) is known to carry less cardiovascular risk treating
abdominal aortic aneurysm (AAA) than open surgery. However, anatomical conditions of the AAA is a
limiting factor of this method. We would like to present a case where circumstances strongly favored an
endovascular procedure, but anatomy unabled completion of the intervention, converting eventually into
open surgery.
Methods: Case report. We report the case of a 67y male presenting with a huge asymptomatic AAA,
as a chance finding. The CT-Scan showed an infrarenal aneurysm with a largest diameter of 11cm, a
cranio-caudal stretch of 10cm and a kinking of the aneurysm with an angle of 115° relative to the neck.
This polymorbid patient (COPD, asbestosis, intermittent atrial flutter, moderate renal insufficiency after
posttraumatic nephrectomy, arterial hypertension, status post urothel carcinoma) is highly susceptible
for an endovascular approach. Therefore EVAR was primarily planned and initially carried out. After the
placement of the trunk (Excluder) and ipsilateral leg endoprosthesis the cannulation of the contralateral
leg failed despite using all possible techniques at hand. In consequence and respecting explicidly the
35
patients wish of a one time treatment, we decided to convert to bridge the remaining leg with a regular
PTFE Gore tube prosthesis end-to-end to the common iliac artery on the left side. The patient showed an
uneventful recovery.
Results: Discussion. The pitfall in our case was the cannulation of the contralateral leg. Routinely, the
approach is done from the ipsilateral groin with direct retrograde intubation of the short leg. However,
there are several alternatives if the first method fails. In a crossover technique, a guidewire is caught by
snare technique on the contralateral side. Furthermore an anterograde catheterization via the brachial
artery may facilitate the placement of the prosthesis. Alternatively, occlusion of the short leg converts the
EVAR to a monolimb procedure and an additional crossover bypass is required. This will avoid laparotomy. Eventually, leaving the short leg open and try the next day, hoping that a thrombus will have led to a
preformed path is another option. Others are using the „ballerina technique“, transposing the limbs to
enhance the cannulation of the limb. This method requires corresponding placement of the trunk already
at the beginning. Ultimately the Anaconda System using magnetic power to facilitate the intubation of the
leg might have been of use in this case.
Conclusion: When using EVAR, several measurements must be prepared to avoid adverse events and
complete an intervention successfully. Anatomic conditions may impede the placing of the prosthesis
and thus one or two alternatives must be at hand. In our case we concluded that an extention with a
conventional PTFE tube will suit our patients situation best.
16.5
Ruptured abdominal aortic aneurysm masquerading as phlegmasia coerulea
P.O. Myers, A. Kalangos, S. Terraz (Genève)
Objective: Abdominal aortic aneurysms (AAA) have a prevalence estimated at 1.0%-8.3% and represent
the thirteenth leading cause of death in the USA, from spontaneous rupture. The annual rupture risk for
AAA greater than 8 cm is 30-50% and mortality after AAA rupture is 65-85%. Because awareness is now
high and screening is easy, the condition is detected early in most patients and treated before complications arise. An unusual and particularly dangerous clinical manifestation of AAA rupture occurs when it
is directed towards the inferior vena cava, creating an aortocaval fistula, which presents as an atypical
cause of phlegmasia cerulea. We present a case in which the clinical presentation, supported by abnormal urinary findings, led to an incorrect presumptive diagnosis of urinary sepsis.
Methods: One observation of ruptured AAA presenting as an aortocaval fistula is presented. CT scan imaging with sagittal and 3D reconstructions are provided.
Results: A 68-year-old man presented with asthenia, chills without fever, macrohaematuria, mild back
pain, as well as oedema and blue mottling of the lower limbs and abdomen for 24 hours. He gave a
history of hypertension, intermittent claudication and 80 pack-years active smoking. On examination, he
appeared in decreased general condition, but was alert and oriented. His temperature was 37.2Â°C, pulse 150 beats/min, and blood pressure 80/54 mmHg. The jugular venous pressure was not raised. The
heart sounds were normal with no murmurs. The lower limbs were warm, severely cyanotic and swollen
with distended superficial veins. The arterial pulses were present and there was no paresis or paresthesis.
The abdomen was mottled, non-tender, with no evidence of pain, pulsatile mass or murmur. In view of the
decreased general condition, chills, back pain and low-diastolic pressure shock, we suspected urosepsis,
although it could not explain the signs of venous congestion of the lower limbs and abdomen. Haemodynamics did not improve after initial fluid resuscitation and norepinephrine was prepared. Blood examination showed an increased white cell count (13.3x10^9/L), C-reactive protein (95 mg/l), creatinine
(135 micromol/L) and lactate (3 mmol/L). Urinary sediment revealed elevated erythrocytes, leucocytes,
nitrites and proteins. Computed tomography showed abnormal enhancement of the inferior vena cava
(IVC) during arterial phase and a large AAA measuring 85 mm in diameter. Reconstructed images revealed a direct communication between the AAA and the IVC. Phlegmasia cerulea dolens-like symptoms
were thus explained by compromised venous outflow from the lower limbs due to an aortocaval fistula.
Emergent surgical repair was attempted, however the patient died of incontrollable haemorrhage.
Conclusion: This case shows that simple clinical signs, such as lower limb venous congestion and high
output congestive heart failure in a patient with cardiovascular risk factors, should alert the clinician to the
possibility of a lethal fistula. Awareness of this form of abdominal aortic aneurysm rupture could reduce
the risk of a fatal outcome.
16.6
Lower digestive tract perforation following prosthetic vascular reconstructions
S. Bommeli, D. Delay, P. Ruchat, E. Ferrari, F. Stumpe, L.K. von Segesser (Lausanne)
Objective: Enterovascular fistulas are feared complications following abdominal aortic surgery. They
usually take place on the upper digetive tract at the level of the duodenum and manifest themselves as
intermittent or cataclysmic hemorrages. In contrast, we present two patients with complications involving
the lower digestive tract.
Methods: The two patients were hospitalized with persistant low grade fever and postive blood culture
for atypical digestive microorganisms 3 years and one month respectively after inital operation. The first
patient had undergone aorto bi-femoral bypass for ischemic vascular disease and the other one insertion
of an aorto-right iliac endoprosthesis plus right femoral to left iliac bypass to cure an abdominal aortic
aneurysm. In both patients CT-Scan demonstrated incorporation of the vascular prosthesis in the sigmoid
colon with local inflammatory reaction. Rectosigmoidoscopy confirmed the intraluminal position of the
prosthesis. Both patients were treated by removal of the incriminated material and construction of an
extra-anatomic bypass. In the first patient, the left leg of the aorto-bifemoral bypass was removed and a
femoro-femoral bypass executed. In the second patient, the right femoral left iliac prosthesis was removed
with construction of a left axillo-femoral bypass. A left colostomy was performed in the first patient while
continuity could be directly re-established in the second patient.
Results: Both patients survived the operation. Histopathology confirmed perforation with associated signs
of inflammation in the two cases. Antabiotic treatment was continued until favorable clinical evolution. The
second patient needed subsequent left femoro-popliteal bypass for progression of his disesase.
36
Conclusion: Lower digestive tract perforations following intraabdominal vascular surgery are rare. They
can manifest themselves as low grade persistant infections and should be sought-after in cases of unexplained positive blood culture for digestive germs. Operative management consists in removal of all the
infectred materiel and revascularization by extrra-anatomic bypass or use of homografts.
16.7
Limits of surgical treatment of aneurysmal disease
V. Bestetti1, W. Mouton1, H. Savolainen2, J. Schmidli2 (1Thun, 2Bern)
Objective: We describe a case with multiple aneurysms not amenable to surgery.
Methods: An 88-year-old male patient presented with chronic pain in his right thigh while sitting. History
included smoking, arterial hypertension and non-insulin dependent diabetes mellitus. Ischaemic heart
disease was known after a previous myocardial infarction. An infrarenal aneurysm with a diameter of
9 cm had been diagnosed in 2003. At that time, the patient had declined surgery due to advanced age.
Bilateral popliteal aneurysms had been operated on in 2001. Clinical examination revealed a pulsatile
abdominal mass together with masses proximally in both thighs.
Results: Investigations: CT scan showed an infrarenal aortic aneurysm with a diameter of 12 cm as well
as iliac, femoral and popliteal aneurysms of up to 11cm in diameter. Angiography showed occlusion of
the distal politeal artery, trifurcation and distal leg arteries. Treatment: No reconstructive surgery was suggested. Endovascular aortic reconstruction was considered too risky with regard to the already compromised distal leg circulation. Symptomatic medical treatment for thigh pains was prescribed.
Conclusion: Advanced age, local anatomy and poor run-off may limit possibilities for surgery in aneurysmal disease – as presented in this extraordinary case of generalised aneurysmatic disease.
16.8
Embolisation eines venösen Port-Systems in das Atrium dextrum nach einer Latenzzeit von über einem
Jahr
S.J. Schwarz, C. Letta, J. Knaus (Lachen)
Objective: Die in vielen Gebieten der Medizin verwendeten Port-Katheter-Systeme zeichnen sich durch
hohe Zuverlässigkeit und gute Handhabung im alltäglichen klinischen Umgang aus. Bei seltenem Auftreten von Komplikationen werden im Allgemeinen in der differentialdiagnostischen Überlegung hauptsächlich Thrombosierungen des Katheters bei der Ursachenklärung favorisiert. Eine Fremdkörperembolisation
im Rahmen eines Port-Systems stellt hier eine sehr seltene Komplikation dar, welche sowohl iatrogen als
auch - wie im vorliegenden Fall- spontan bedingt sein kann.
Methods: In diesem Fall berichten wir über eine 48-jährige Patientin, welche seit 2004 mittels adjuvanter
Chemotherapie bei einem metastasierenden Mammakarzinom behandelt worden war. Im September
2006 wurde ein Port-a-Cath-System in die rechte Vena subclavia implantiert mit anschliessend unauffälliger radiologischer und klinischer Kontrolle. Eine weitere Röntgen-Thorax-Aufnahme einen Monat später
zeigte bereits eine zu diesem Zeitpunkt nicht erkannte Schädigung des Katheters im Bereich des kostoclaviculären Winkel.
Zusätzlich war drei Monate nach Implantation bei weiterhin problemloser Medikamenten-Instillation
durch das Port-System die Blutentnahme auch nach zahlreichen Versuchen nicht mehr möglich. Über ein
Jahr darauf stellte sich die Patientin im Rahmen eines weiteren chemo-therapeutischen Zyklus mit einer
spontan aufgetretenen Schwellung unter dem rechten Schlüsselbein vor.
Results: Die daraufhin angefertigte Kontrastmittel-Aufnahme verwies auf eine im Verlauf entstandene Paravasation der Vena subclavia im Bereich der Katheterläsion mit Rekanalisation des Kontrastmittels ohne
vollständigen Abriss. Die im Anschluss angefertigte Röntgen-Thorax-Aufnahme zeigte bereits eine nun
komplette Ruptur des Port-Katheters mit Embolisation in das rechte Atrium.
Nach direkter Verlegung in das Herzkatheterlabor des Universitätsspital Zürichs erfolgte die Bergung des
abgerissenen Endstücks über einen femoral-venösen Zugang mittels intravaskulärem Rückholset nach
Dotter; nachfolgend die ambulant-operative Entfernung des implantierten Port-a-Cath-Hauptstücks.
Conclusion: Bei liegenden Port-Systemen muss bei Auftreten von unklaren bzw. unspezifischen Beschwerden wie z.B. atraumatische Schwellung, Herzrhythmusstörungen oder bei Verdacht auf eine
Paravasation neben einem „Pinch-off“-Phänomen auch die Ruptur des Katheters bzw. Embolisation von
Katheter-Teilstücken als Differentialdiagnose in Betracht gezogen werden. Die Thorax-Übersichtsaufnahme genügt in aller Regel zur Diagnosesicherung.
16.9
Even the safest technique may not be 100% safe
R. von Allmen, D. Danzer, I. Schwegler, J. Schmidli (Bern)
Objective: Insertion of a chest tube is generally perceived as an easy and safe intervention, particularly
if usage of a trocar is avoided. We describe a iatrogenic injury to a major thoracic vessel despite blunt
insertion technique with abandonment of the trocar.
Methods: We report the case of a 77years old lady who had originally been admitted for a ruptured thoraco-abdominal aortic aneurysm and undergone a successful thoraco-abdominal aortic replacement.
After successful management of early complications (i.e. pneumonia and temporary renal failure) she
had been transferred to another hospital for rehabilitation in a stable condition. On the 10th postoperative
day she was readmitted because a thoracic drain had newly been placed for a symptomatic pleural effusion and delivered whole blood.
Results: We found a stable and alert patient with a 20 French chest tube inserted into the left anterior
axillary line at 8th intercostal space level. Placement had reportedly been performed by blunt dissection
technique and without usage of a trocar. Upon insertion, however, the tube had drained whole blood with
pulsatile flow and immediately been clamped. A contrast enhanced computed tomographic angiography
revealed the tube to lie with its tip within the left pulmonary artery. A rescue operation was performed
via a left re-thoracotomy. The tube had perforated the lingula and a segmental artery on its was into the
left main pulmonary artery. Hemostasis was achieved by direct vessel suture after removal of the tube.
Postoperative course was uneventful.
Conclusion: The inherent rigidity of a thoracic tube may suffice by itself to injure lung tissue or the pulmonary vascular tree despite widespread abandonment of the formerly common sharp insertion technique by
a pointed trocar. Particularly in the presence of a “hostile thorax” (e.g. after major thoracic surgery) utmost
cautiousness during chest tube insertion is mandatory and severe iatrogenic complications may occur
even during seemingly smooth procedures.
16.10
Inferior vena cava thrombosis by congenital infrarenal caval hypoplasia: a case report
R. Galli1, P.A. Stalder1, L. Gürke2, S. Schlunke3, R. Rosso1 (1Lugano, 2Basel, 3Locarno)
Objective: Anomalies of the inferior vena cava often become symptomatic in association with extensive
caval vein and lower extremity deep vein thrombosis, which may present with a wide spectrum of signs
ranging from phlegmasia coerulea dolens to abdominal organ failure or pulmonary embolism. We report
a case of symptomatic hypoplasia of the inferior vena cava and proceed to a short literature review.
Methods: A 39 year old man with a history of immobilization due to a previous back trauma was admitted
with a clinical picture of phlegmasia coerulea dolens of both legs. Radiologic work-up documented a
bilateral thrombotic occlusion of the iliofemoral veins extending as far as the inferior vena cava, which
appeared hypoplastic until the confluence of the pelvic veins. The patient underwent a combination of bilateral thrombectomy of the iliofemoral veins with catheter-directed thrombolysis, balloon angioplasty and
stenting of the caval vein, which led to initial restoration of the venous perviety. Additionally a vena cava
filter was implanted. The procedure was followed by bilateral reocclusion of the iliofemoral veins necessitating a second, unsuccessful thrombectomy. Since postoperative course was marked by regression of
edema and perviety of the infrainguinal deep venous system, further surgical treatment could be avoided.
A long-term conservative therapy with phenprocoumon was started and angiologic monitoring planned.
Results: Dysgenesis of the inferior vena cava has an estimated prevalence of 0.3 to 0.5% in otherwise
healthy individuals. In adults such anomalies are usually asymptomatic and discovered incidentally in abdominal surgery or radiologic work-up. However, some patients might become symptomatic developing
venous stasis and subsequent thrombosis. CT and MRI are the most indicated methods in the evaluation
of anomalies of the inferior vena cava and allow the visualization of correlated congenital anomalies.
Screening tests for thrombophilia should be performed as dysgenesis of the inferior vena cava has been
described in coincidence with clotting defects. Available treatments range from conservative anticoagulant therapy to systemic thrombolysis, endovascular interventions such as catheter-directed thrombolysis
combined to balloon angioplasty and stenting, and surgical procedure such as thrombectomy or venous
bypass. Despite insufficient evidence, authors tend to prefer less invasive procedures aiming at restoring
venous perviety, instead of correcting the background congenital anomaly.
Conclusion: Anomalies of the inferior vena cava are a rarity but should be considered in young adults
who present with thrombosis involving both iliac veins. Treatment is necessary in case of symptomatic venous thrombosis and should be individualized according to clinical manifestation and to the degree and
localization of the obstruction. Lifetime oral anticoagulation is indicated due to the high risk of thrombotic
recurrence, and thromboembolic risk factors should be strictly avoided.
16.11
Symptomatische Ektasie der Vena jugularis externa
S. Azizi1, R. Bühlmann1, L. Gürke2, P. Stierli1 (1Aarau, 2Basel)
Objective: Die Phlebectasie der Jugularvenen ist eine seltene, vor allem im Kindesalter beobachtete abnorme fusiforme Venendilatation. Sie betrifft vor allem die Vena jugularis interna (Jianhong et al 2006).
Ihre Aetiologie ist unklar, postuliert wird eine kongenitale Ursache. Allerdings wurde sie auch im Rahmen
des Menkes-Syndrom, eine hereditäre Bindegewebs-erkrankung (Price DJ et al 2007) und nach zervikovertebralem Trauma (Teodorescu et al 1978) beschrieben. Anhand eines Fallberichtes möchten wir die
Indikation der operativen Sanierung besprechen.
Methods: Fallbericht. Wir berichten über eine 65-jährige Patientin mit einer schmerzhaften Schwellung
supraclaviculär links seit zwei Monaten. Zu dieser Zeit wurde eine Cortison-Therapie bei Polymyalgia
rheumatica begonnen. Sie war vor allem im Liegen so gestört, dass sie halbaufrechtsitzend schlafen
musste. Die Duplexsonographie und die Computertomographie zeigten eine segmentale Erweiterung der
Vena jugularis externa oberhalb der Clavicula. Es bestand kein Hinweis auf eine Abflussbehinderung. Der
ektatische Segment wurde exzidiert. Histologisch zeigte sich eine Phlebosklerose. Postoperativ verspürte
die Patientin keinerlei Beschwerden mehr.
Results: Diskussion. Die Phlebectasie der Jugularvenen wird meistens als asymptomatisch beschrieben. Wie in unserem Fall wurde jedoch bereits über assoziierte Beschwerden, wie Zungenschmerzen
(Stofman GM et al 1997) und Stimmveränderung (Lubianca-Neto JF et al 1999) berichtet. Ueber eine begleitende Thrombenbildung wurde bisher nicht rapportiert. Die Phlebectasie der Jugularvenen imponiert,
wie die Laryngozoele, als weiche zervikale Schwellung während dem Valsalva-Manöver. Die klinische
Verdachtsdiagnose wird am besten mittels farbkodierter Duplex-sonographie bestätigt (Jianhong et al
2006). Betreffend der operativen Versorgung werden einfache Ligaturen bzw. Exzisionen wie auch, beim
Befall der Vena jugularis interna, Lumenverkleinerungsplastiken mittels raffender Längsnaht und zusätzlicher Umhüllung mit Dacron bzw. PTFE (Jianhong et al 2006) oder mittels Umhüllung der Vene mit dem
M. sterno-cleidomastoideus (Gao Y et al 1999) beschrieben.
Conclusion: Die Phlebectasie der Jugularvenen ist eine benigne Erkrankung mit seltenem Krankheitswert.
Die Ligatur bwz. die Exzision des ektatischen Venensegmentes ist nur bei Symptomen oder aus kosmetischen Gründen indiziert.
16.12
Kurzzeitresultate und Patientenzufriedenheit nach Varizenoperation
M. Mastrocola, H. Würsten, U. Laffer (Biel)
Objective: Als häufige Venenerkrankung führt die Varikose bei ca. 15% der Betroffenen im Verlaufe des
Lebens zu einem erheblichen Leidensdruck. Die Varizenchirurgie spielt hier eine wesentliche Rolle indem
sie das Fortschreiten der Krankheit und das Auftreten der Komplikationen reduzieren kann. Ziel dieser
Studie war die Analyse der Kurzzeitresultate und Patientenzufriedenheit nach Varizenoperation.
Methods: Prospektive Daten von 225 Patienten, die sich zwischen 01/04 und 10/07 einer Varizenoperation unterzogen haben, wurden ausgewertet. Dabei wurden in einer klinischen Kontrolle 3 Monate
nach Eingriff, neben den postoperativen Komplikationen, folgende Parameter berücksichtigt: Narbenverhältnisse, postphlebitische Veränderungen, Sensibilitätsstörungen, Restkonvolute und neu aufgetretene
Konvolute. Zudem wurden die Patienten nach ihrer subjektiven Zufriedenheit befragt.
Results: Die postoperative Rate der schwerwiegenden Komplikationen betrug 0.8% (eine Lungenembolie, ein Wundinfekt). Dabei kam es zu keinen Verletzungen an grossen Gefässen oder Nerven. Als leichte
Komplikationen (16.8%) fanden sich 30 Fälle kutaner Nervenläsionen (13.3%), 2 Fälle von Lymphozelen (0.9%), 3 Fälle von persistierenden Beinödemen (1.3%) und 3 Fälle von postphlebitischen Veränderungen (1.3%). Die kutanen Nervenläsionen zeigten sich in lokal begrenzten Sensibilitätsstörungen
(diffuse Schmerzen: 3.1%, lokale Hypästhesien: 13.3%). Auffällige Narbenverhältnisse, im Sinne von reizlosen Verhärtungen, wurden in 4.9% gefunden. Bei 7.1% der Patienten bestanden Restkonvolute und bei
2.2% waren neue Konvolute aufgetreten. 90.2% der 225 Patienten äusserten sich zum Operationsresultat
zufrieden bis sehr zufrieden.
Conclusion: Die Rate der schwerwiegenden Komplikationen (0.8%) liegt im Bereich der in der Literatur
beschriebenen Daten. Bei den leichten Komplikationen (16.8%) herrschen Sensibilitätsstörungen mit
diffusen Schmerzen und lokal begrenzten Hypästhesien auf Grund von kutanen Nervenläsionen vor, die
konservativ gut behandelbar sind. Eine äusserst präzise präoperative Markierung der Varizenkonvolute,
allenfalls mittels Duplexsonographie, könnte, durch die daraus folgende genauere Phlebektomie, das
Vorkommen lokaler Hypästhesien reduzieren. Die vorliegenden Daten zeigen eine hohe Zufriedenheit der
Patienten bezüglich des Operationsresultates.
16.13
Vacuum-Assisted Closure (VAC) used for fasciotomy closure in ischemia-reperfusion syndrome
S. Karaca, D. Kamentsidis, A. Kalangos (Genève)
Objective: Traumatic compartment syndrome and ischemia-reperfusion syndrome after surgical revascularisation in case of long acute vascular ischemia syndrome may require early fasciotomy. In the
past those fasciotomies needed prolonged hospitalisation and decreased number of dressing changes.
In case of fasciotomy closure by skin graft, many complications have presented because of the large
wounds and infections. Theses cases often required several surgical interventions until closure. This VAC
therapy system is an innovative method which promotes excellent wound healing, preparation of the
wound bed, keep the wound clean until fasciotomie closure.
Methods: In our study four patients were operated for acute ischemic vascular disease. A fasciotomy has
been performed in these patients after presenting with an ischemic-reperfusion syndrome in the upper
extremities during the first 12 hours post operatively.The VAC has been instaured as a treatment (median
5 days after surgery) in all cases.
Results: The difficulty of closure lies on either tissue defect or important wound edema or both. The patients had closure of the fasciotomy wound in 7 to 15 days after surgery. In two cases the fasciotomy
closure was performed with adjacent skin. The other two patients needed small skin graft for closing the
fasciotomy wound.
Conclusion: The use of the VAC system for after fasciotomy reduced significativly the wound edema, stimulated the granulation of tissue, reduced the size of the wound, showed an important wound protection
for infection and reduced the dressing changes. The VAC system permitted in our hands early closure of
the fasciotomy wounds with adjacent skin or skin graft.
16.14
Behandlung chronischer Wunden mit Medihoney
R. Lässker, C. Medugno, P. Wigger (Winterthur)
Objective: Für die Behandlung chronischer Wunden an den unteren Extremitäten wurden in den letzten
Jahren verschiedene, insbesondere okkludierende Verfahren entwickelt. In gewissen Situationen, bei Ausschöpfung von herkömmlichen, modernen Wundkonzepten, hat uns eine alte Methode geholfen: Honig.
Wir haben die Methode in ausgewählten Fällen angewendet und beschreiben die Resultate.
Methods: In zwei langwierigen, komplexen Fällen wurde 2007 eine Wundbehandlungen mit Wund-auflagen mit Medihoney durchgeführt. Dabei handelt es sich um eine standardisierte Honig-mischung, welche
gammasterilisiert wird. Der Verlauf und die Resultate wurden dokumentiert und fotographisch festgehalten. Die Kosten der Behandlung wurden bezüglich Personalkosten und Materialaufwand analysiert.
Results: In beiden Fällen wurde nach vorgängiger Stagnation unter der neuen Behandlung mit Honigauflagen rasch deutliche Fortschritte erzielt. Es sind keine Infektionen aufgetreten. Die Patienten waren
zufrieden mit der Behandlung, insbesondere durch die schmerzarmen Verbandswechsel und die deutlich
geringere Geruchsbelastung. Die Kosten sind ähnlich zu denen der konventionellen Behandlung, wobei
der Hauptanteil durch die Personalkosten entsteht.
Conclusion: Die Behandlung chronischer Ulcera mit Auflagen aus Honig ist bei ausgewählten Fällen
eine vielversprechende Methode. In den untersuchten Fällen wurden deutliche Fortschritte unter dieser
Behandlung erzielt. Die Kosten sind gegenüber der konventionellen Behandlung vergleichbar.
37
17
17.1
Modern wound care for developing countries: a randomized clinical trial in Haiti comparing the vacuum
system with conventional wet dressings
D. Perez1, M. Bramkamp1, C. Exe2, C. Von Rüden1, A. Ziegler2 (1Zürich, 2Deschapelles/HT)
Objective: This trial was carried out to determine whether a simple homemade wound vacuum dressing
system (HM-VAC) is a feasible alternative to the use of conventional saline soaked gauze (WET) dressings
for the treatment of complex wounds in an underdeveloped country’s hospital setting. A clinical randomized study was performed to this effect.
Methods: Forty patients with a total of 40 acute and chronic wounds were observed over a period of 5
months in a randomized trial comparing two different wound dressing regimens: The HM-VAC and the
WET dressings. The HM-VAC was assembled with common tools available in most operation rooms
worldwide. The primary outcome measure was the time required to achieve complete healing (in days) of
the wound. In addition, the costs of the HM-VAC and the WET dressing treatments were calculated.
Results: The median time required to achieve complete healing was 16 days (95% confidence interval
[CI], 14.2 to 23.1) in the HM-VAC group compared with 27 days (95% [CI], 23.1 to 32.1) in the WET group
(P = 0.013). The HM-VAC treatment cost 5.6 US$ (95% [CI], 2.9 to 8.1) per day, and the WET management
1.7 US$ (95% [CI], 1.3 to 2.5) per day of treatment (P = 0.034).
Conclusion: The HM-VAC should be used in less and least developed countries to provide the optimal
management for complex wounds since healing is significantly faster compared to conventional wound
care. Although the HM-VAC is more costly than the conventional approach, it is probably affordable for
most hospitals in underdeveloped regions. Further studies with a larger number of patients and longer
follow-up are justified and recommended.
17.2
Statistical knowledge in the swiss surgical community: do we need improvement?
A.P. Businger, S. Engelberger, U. Güller (Basel)
Objective: Statistical knowledge becomes increasingly important in the current age of evidence-based
medicine. Understanding basic statistical concepts enables critical reading of medical literature, its implementation in clinical practice, and the conduct of methodologically sound research. The objective of the
present investigation was to evaluate the level of statistical knowledge in the Swiss surgical community.
Methods: Seventy-eight surgeons/surgical residents were interviewed by telephone. A standardized protocol containing 23 questions assessed subjects’ knowledge of a variety of basic statistical concepts. The
maximum number of points possible was 27, and the minimum number was 0. Mann-Whitney-U-tests
were used to compare the average scores between different subgroups. The level of statistical significance was set at 0.05. All tests were two-tailed.
Results: The median age was 32 years (range 27 to 54), and 52 of 78 subjects (67%) were male. Overall,
58 residents, 11 attendings (OA), and 9 chiefs/vice-chiefs were interviewed. While some questions were
answered very well (correct definition of double-blind study: 78/78 participants; correct definition of multivariate analysis: 73/78 participants; correct definition of sensitivity: 65/78 participants), a profound lack
of knowledge was observed in other fields (correct definition of type I error: 13/78 participants; correct
difference between c2-test and Fisher’s exact test: 26/78 participants; correct definition of censoring in
Kaplan-Meier curves: 17/78 participants). The median overall score of all participants was 13 (range
6 to 27). Subjects who participated in a statistics or scientific writing course (median score: 15) had
significantly better statistical knowledge compared with those who did attend such a course (median
score: 10, p < 0.0001). No significant difference in overall score was observed between women (median
score: 12.5) and men (median score: 14, p = 0.98) or between attendings/chiefs (median score: 13) and
residents (median score: 13.5, p = 0.79).
Conclusion: The average statistical knowledge in the Swiss surgical community is mediocre, and a
serious lack of knowledge exists in certain statistical areas. While no significant difference was found
between male and female participants or between surgical residents and attendings/chiefs, participants
who took a course in statistics/scientific writing performed significantly better compared with those who
did not. It is thus desirable that all surgeons and surgical residents attend a statistical course, and we
clearly need to improve our statistical knowledge.
17.3
Vital indizierte Bluttransfusion in der Elektiv- / Notfallsituation beim Urteilsfähigen / Nichturteilsfähigen
– Behandlungsleitlinie im Falle der Transfusions-Verweigerung
A. Roggo (Bern)
Objective: Bestimmung der forensischen Erfahrung ud Relevanz im Zusammenhang mit zwar vital indizierter, jedoch abgelehnter Bluttransfusion bei Angehörigen der Zeugen Jehovas, um daraus mögliche
Vorgehensweisen für die Praxis abzuleiten.
Methods: Im Rahmen einer in dieser Dimension erstmals erstellten Feldstudie wurden zur Evaluation
eines Beobachtungs-Zeitraums von 20 Jahren (1986 – 2005) 529 standardisierte Fragebogen versandt.
Befragt wurden schweizweit alle Akutspitäler, kantonalen Gerichte erster und zweiter Instanz und das
Bundesgericht; zudem die kantonalen Vormundschaftsbehören, Sanitätsdirektoren und Kantonsärzte.
Ergänzend wurden Interessengruppen der medizinischen Fachgesellschaften und Haftpflichtversicherer
im Gesundheitswesen einbezogen.
Results: Total 382 der 529 Fragebogen wurden zurückgesandt, was einer überdurchschnittlich hohe
Quote von 72% entspricht. Insgesamt wurden nur 6 Ereignisse zum untersuchten Thema festgehalten:
Eine Meldung kam von einem Kantonsarzt; 5 aus Akutspitälern (in einer Situation mit Todsfolge wurde
diese als Offizialdelikt strafrechtlich anhängig gemacht, das Verfahren bereits auf Untersuchungsrichte-
38
rebene wieder eingestellt). Keines der antwortenden Gerichte (205 aus 281 angeschrieben) hatte letztenendes jemals über einen entsprechenden Streitfall zu entscheiden. Bei Haftpflichtversicherungen bzw.
Standesorganisationen gingen keine Meldungen ein.
Conclusion: Bekanntlich lehnt nur eine Minderheit der Bevölkerung im Ernstfall eine Bluttransfusion ab,
aus welchen Gründen auch immer. Dennoch ist die inhaltliche Brisanz für klinisch tätige Ärzte im Einzelfall hoch, da von ihnen gerade in der Notfallsituation ein rascher Entscheid erwartet wird. Diese Ärzte
sind dann nur allzuoft einer beinahe unlösbaren, paradoxen juristischen Pflichtenkollision (handeln zur
Lebensrettung / unterlassen in Achtung des Selbstbestimmungsrechts?) und damit einem Spannungsfeld zwischen „juristischem Recht“ und dem geleisteten „hippokratischen Eid“ ausgesetzt. Oft entsteht
gerade aus dieser Pflichtenkollision und einer verbreiten Grauzone bezüglich Rechtssicherheit ein Gewissensnotstand, der den meisten Ärzten hinlänglich bekannt ist. Die Abteilung für Medizinrecht / Institut
für Rechtsmedizin Universität Bern trägt den in der Feldstudie erhobenen Resultaten und der allgemeinen
Problematik Rechnung. An hand eines möglichen strukturierten Lösungsweges werden entsprechend
Algorithmen vorgestellt und damit offen thematisiert: Vital indizierte Bluttransfusion Ja / Nein bei einem
Urteilsfähigen / Nichturteilsfähigen in einer Elektiv- / Notfall-Situation Wie kann / muss / darf sich der
behandelnde Arzt entscheiden?
17.4
The surgeon and the profession
A.P. Businger1, S. Rinderknecht1, C. Sommer2, P. Villiger2, M. Furrer2 (1Basel, 2Chur)
Objective: Recent years have shown declining interest in pursuing a surgical residency. Several studies
of students and residents have revealed multiple factors for the decreased rates of applications for a surgical residency. The goal of the present study was to explore the arguments given by board-certificated
surgeons in Switzerland for and against a career in surgery.
Methods: As part of a study of surgical research networks in Switzerland, surgeons were asked to answer
two free-response questions on arguments for and against a career in surgery. Subjects also were asked whether they would choose surgery again as a career. The arguments were analyzed by Maryring’s
content analysis.
Results: Three hundred and thirty-four surgeons made 790 statements for and 981 statements against
a career in surgery. Fifty-nine (17%) would not choose surgery again as a career. Maryring’s content
analysis of the statements yielded 10 categories with arguments both for and against a career in surgery.
Personal experience in daily life (18.7%) was the top-ranked category in favor of a career in surgery, and
specialty structural condition (19.2%) was the top-ranked category against. The statements differed only
slightly with respect to gender, subspecialization, and hierarchical position. Ordinal logistic regression
showed that the category “personal experience” (odds ratio, 2.39; 95% confidence interval, 1.13 to 5.07)
was independently associated with again choosing surgery as a career, and the category “health-policy“
(odds ratio, 2.69; 95% confidence interval, 1.42 to 5.10) was associated with not again choosing surgery
as a career.
Conclusion: The arguments of board-certificated surgeons for and against a career in a medical profession are quite similar to those of residents and students. The surgeons’ main complaints were unfavorable
working conditions and regulations. New organizational frameworks and professional perspectives are
required to maintain highly qualified and motivated surgeons in the surgical profession.
17.5
Opfer von Gewalt auf einer Notfallstation – eine prospektive Studie
K. Kessel, A. Ringger, U. Laffer (Biel)
Objective: Die Behandlung von Gewaltopfern ist weltweit ein grosses Problem. Insbesondere in der Nacht
ist schätzungsweise jeder zweite bis dritte Patient, der auf der chirurgischen Notfallstation versorgt wird,
in eine Gewaltsituation verwickelt gewesen. In der vorliegenden Studie galt es insbesondere die Schwere
der Verletzungen, sowie die entstandenen Kosten und Hintergründe der Gewalttaten zu untersuchen.
Methods: Vom Juli bis Dezember 2007 wurde auf unserer chirurgischen Notfallstation anhand eines Fragebogens prospektiv jeder Patient, der in eine Gewalttat mit jeglicher Verletzung verwickelt war, erfasst.
Keine Ausschlusskriterien. Die Daten wurden erhoben zum genauen Tathergang, Verletzungsgrad und
die damit verbundene Behandlung, die verursachten Kosten, sowie exakte Patientenangaben.
Results: In der erwähnten Periode wurden insgesamt 100 Patienten erfasst. Davon waren 53% Schweizer (im Vergleich zur städtischen Gesamtbevölkerung, die zu 27% aus Ausländern besteht). Der Ausländeranteil bestand grösstenteils aus Afrikanern und Mittel- und Südeuropäern. Etwa die Hälfte der
Behandlungen erfolgte in der Nacht, wobei das durchschnittliche Alter der Patienten bei 29 Jahren (zwischen 16 und 58) lag, mit einem Männeranteil von 75%. 55% der Gewalttaten wurden im Freien verübt,
in etwa 49 % aller Fälle unter Alkoholeinfluss. 89% gaben an, Opfer der Auseinandersetzung gewesen zu
sein, wobei der Gegner in 46% der Fälle bekannt war. 26% der Patienten wurden mit Gegenständen wie
z.B. Schlagringen, Flaschen, Stöcken, Steinen verletzt, 8% mit einem Messer und 65% wurden mit Fäusten geschlagen. Die Schwere der Verletzungen reichte von Kontusionen (40%) und RQWs (17%) über
Commotio cerebri (17%) und Frakturen (14%) bis hin zu schweren Messerstichverletzungen (8%) mit
der Notwendigkeit einer postoperativen intensivmedizinischen Überwachung. Insgesamt mussten 28%
der Patienten stationär behandelt werden. Die verursachten Kosten betrugen im Durchschnitt 1.186,- CHF
pro Patient (zwischen 96,- und 20.751,- CHR), was Gesamtkosten von 120.000,- in knapp 6 Monaten
entspricht.
Conclusion: Eine vergleichbare Studie am Inselspital Bern konnte eine Zunahme der Verletzungen aufgrund von Gewaltverbrechen in den letzten Jahren aufzeigen. Auch wir gehen davon aus, dass das
Ausmass der Gewalt und die Schwere der Verletzungen in den letzten Jahren tendentiell zunehmend
ist. Dies lässt vermuten, dass in der Gesellschaft ein zunehmendes Gewaltpotential vorhanden ist und
es gilt zu diskutieren, inwiefern hier Massnahmen auf politischer Ebene zu treffen sind. Wie in vielen anderen Bereichen des Sozialwesens trägt sicher auch die Zunahme von Gewalttaten zur Steigerung der
Gesundheitskosten bei!
17.6
Wintersport: der Helm verhindert die commotio cerebri nicht!
A. Grosskreutz, D. Heim (Frutigen)
Objective: Die commotio cerebri ist im alpinen Wintersport eine häufige Diagnose. Helmtragen ist heutzutage immer häufiger und wird zur Modesache. Gibt es damit weniger commotiones?
Methods: Seit 1995 wird auf unserer Notfallstation eine Statistik aller Wintersportunfälle erhoben. Alle Patienten der Saison 2006/07 mit einer commotio cerebri wurden retrospektiv telefonisch zum Helmtragen
befragt. Die Diagnose commotio cerebri, auch leichtes Schädel-Hirn-Trauma genannt, wurde gestellt bei
Bewusstseinsverlust weniger als 5 Minuten und einer Reversibilität innerhalb von 5 Tagen sowie einem
GCS von 13-15.
Results: Von der Wintersaison 96/97 bis 05/06 (10 Jahre) wurden insgesamt 3757 Patienten erfasst.
343 hatten eine commotio, dabei handelte es sich um 178 alpine Skifahrer und um 135 Snowboarder
sowie 30 anderer Sportarten. Die Tendenz über die letzten 10 Jahre zeigt eine leichte Zunahme dieser
Verletzung, relativ gesehen (in Relation zu den verkauften Skiabonnemente der Region Adelboden-Lenk)
ist diese Zunahme jedoch nur unbedeutend. Vom 1.12.06-1.5.07 wurden 450 Patienten versorgt. Eine
commotio cerebri wiesen 43 Patienten auf. Es handelte sich um 29 alpine Skifahrer, 13 Snowboarder
soft, 1 Snowboarder hard. Von diesen Patienten wurden 1 alpiner Skifahrer und 1 Soft-Snowboarder
wegen schwererer Kopfverletzung verlegt. 22 von den bei uns stationären Patienten gaben an, zur Zeit
des Unfalls einen Helm getragen zu haben. Keinen Helm trugen 16 Patienten. 3 Patienten machten keine
Angaben. Alle Patienten wurden während rund 24 Stunden neurologisch überwacht. Schwere Verläufe
wurden keine verzeichnet.
Conclusion: Helmtragen im alpinen Wintersport verhindert eine commotio cerebri nicht, dürfte aber für
den Schweregrad der commotio eine Rolle spielen.
17.7
Benefit of a single preoperative dose of antibiotics in a sub-saharan district hospital: minimal input, massive impact
F. Saxer1, A. Widmer1, J. Fehr1, I. Soka2, P. Kibatala2, H. Urassa2, H. Mshinda2, R. Frei1, T. Smith1,
C. Hatz1 (1Basel, 2Ifakara/TZ)
Objective: To evaluate the impact of a single shot preoperative antimicrobial prophylaxis in reducing the
rate of surgical site infections (SSI) in an African hospital with very limited resources we implemented
standardised guidelines with one dose of Amoxicillin/Clavulanic Acid within 2 hours prior incision.
Methods: In this rural district hospital in southern Tanzania an average of 150 surgical interventions is
performed in two operating theatres every month. Ventilation is achieved by a defective air condition
and open windows. Household soap is used for scrubbing. Instruments are reprocessed by either heat
(150°C for 1h) or steam (134° C for 5min, temperature sensitive devices at 121 °C for 20min); a chemoindicator is in use with every sterilisation process. In a four month period in 2004, patients admitted for
clean or clean-contaminated interventions had been included as pre-intervention group. The perioperative
management differed depending on the surgeon. Patients admitted in the same setting in 2005 were
enrolled as intervention group. They received one dose of 2.2g Augmentin® as intravenous infusion within
2 hours before incision. The substance was targeted at the bacteriologic pattern detected in SSIs of the
pre-intervention group. Patients were assessed daily and 30 days postoperative; in case of SSIs they received free diagnostic workup and treatment. Infections were identified according to the CDC classification;
samples were analyzed by Gram stain and agar (CHROMagar Orientation and CHROMagar S. aureus) in
the local laboratory and the University Hospital Basel using standard methods. Data were reviewed by a
senior infectious diseases specialist with full chart review.
Results: In the pre-intervention group 527 patients qualified for routine antimicrobial prophylaxis that was
administered in 88% after incision and did not cover the expected pathogens to a large extent. One hundred and fourteen patients (21.6%) developed an SSI with 60% of detected pathogens being resistant to the
administered antibiotics. After implementation of the guidelines, the incidence of surgical site infections
significantly decreased from 21.6% to 4% (11/276).
Conclusion: The implementation of a single shot antimicrobial prophylaxis dramatically decreased the
rate of surgical site infections in a hospital with very limited resources. Such guidelines - though developed
for industrialized countries - are even more effective in non-industrialized countries.
17.8
Dyspnée aiguë mimant un pneumothorax sous tension
D. Azagury, W. Karenovics, D. Stähli, J. Mathis, R. Schneider (Neuchâtel)
Objective: Prise en charge d‘un gastrothorax sous tension - présentation de cas.
Methods: Une patiente de 86 ans est transférée dans notre hôpital en détresse respiratoire aiguë : patiente
léthargique, cyanotique, avec hypotension et tachycardie, pH 7.22, saturation < à 80% à l’air ambiant,
asymétrie thoracique nette tant visuellement qu’à l’auscultation pulmonaire, hypertympanisme unilatéral.
Dans ce contexte, une tentative de ponction de décompression à l’aiguille fut faite sans effet.
Results: La radiographie du thorax démontra non pas le diagnostic suspecté de pneumothorax sous
tension, mais celui d’un «gastrothorax sous tension».
La mise en place rapide d’une sonde naso-gastrique se traduisit par une résolution quasi immédiate et
l’amélioration drastique d’un état clinique préalablement critique.
Après équilibrage de tous les paramètres, notamment hémo-dynamiques, la patiente put, par la suite,
bénéficier d’une cure chirurgicale semi élective: réduction du gastre par voie abdominale et gastropexie
avec rapprochement des pilliers. Intervention suivie d‘une excellente évolution post opératoire.
Conclusion: Le gastrothorax aigu est une complication classique des hernies hiatales par roulement,
mais reste extrêmement rare (à notre connaissance, seuls 3 cas similaires ont été décris dans la littérature récente). Cette complication dont la présentation clinique est tonitruante, peut être rapidement
mortelle si aucune mesure thérapeutique n‘est immédiatement entreprise. Celle ci, extrêmement simple,
consiste à poser sans délai une sonde naso-gastrique de décompression. Toutefois, au vue du caractère
rapidement létal du pneumothorax sous tension, il est légitime d‘évoquer ce diagnostic sur la base de
la clinique seule. Dans ce cas, et en face d‘une dyspnée aiguë sévère, la thoracocentèse à l‘aiguille doit
être faite sans attendre la radiographie. De plus, cette manœuvre s‘avère être sans répercussion négative
dans la situation hautement exceptionnelle d’un gastrothorax aigu.
17.9
The impact of wintersport injuries – a prospective study from 96/97 to 05/06: 10-years experience in
a rural hospital
K. Altgeld1, D. Heim2 (1St. Gallen, 2Frutigen)
Objective: Wintersport is in Switzerland the most important sportactivity apart from football. Half of all
accidents happen in football, wintersport and cycling. Thus, wintersport-accidents have an important sociooeconomic impact and merit close attention. Is the the amount of accidents over the years increasing
and what is the impact of these injuries?
Methods: Our hospital is near the wintersport-resorts Adelboden and Kandersteg. From the season 96/97
to 05/06 all accidents treated in our institution have been prospectively recorded. For each patient a questionnaire has been filled out and analysed at the end of each season. The number of accidents has been
put into relation to the number of sold wintersport-tickets.
Results: 3757 patients have been registered in the last 10 years in our hospital, 2/3 are men (median
age 27.4y) and 1/3 are female (median age 28.6y). The absolute number is increasing since 2002, a
peak was reached in the season 02/03 with 500 patients. A very slight increase of the relative number
of accidents is noted since 2000. 50% of all patients are between 11 and 30 years. 60% are skiers, 30%
snowboarders and 10% others. Sledge-accidents are increasing in the last 4 years. The amount of collision accidents remained stable with 11%. The injury pattern did not change over these last 10 years: 38%
upper extremity (more snowboarder than skiers), 34% lower extremity (more skiers than snowboarders),
15% trunk and 13% head and neck injuries. 62% of the patients have been treated as outpatients, 23%
remain < 24 hours in hospital and only 15% stay > 24 hours.
Conclusion: Wintersport-accidents show a slight relative increase since 2002. The relation male-female
is constant. The injury pattern is constant these last 10 years with a predominance of the upper extremity.
The bigger part of the accidents can be treated ambulatory or on a one-day basis. Only 15% are more
severely injured to stay more than 24 hours. Wintersport is fun, but no fun without risk.
17.10
Perkutane Sklerotherapie als Behandlung von postoperativen, inguinalen Lymphozelen
M. Bundi, R. Bühlmann, A.K. Kostorz, R. Schlumpf (Aarau)
Objective: Lymphozelen sind eine bekannte Komplikation nach Chirurgischen Eingriffen, insbesondere
mit inguinalem Zugang. Sie werden mit einer Häufigkeit von bis zu 30% angegeben. Als therapeutische
Optionen bietet sich nebst Kompression und externer Drainage, die perkutane Sklerotherapie oder die
offene chirurgische Wundrevision an.
Methods: Wir berichten über einen 70 jährigen Patienten mit inguinaler Lymphozele nach Seromexzision inguinal in Folge einer Femoralhernienoperation 6 Monate zuvor. Das tägliche Drainage-volumen
von 300-400ml persistierte trotz mehrtägiger Kompression. Eine durchgeführte Lymphographie des
betroffenen Beines dokumentierte die Lymphleckage. Als letzte therapeutische Option vor chirurgischer
Wundrevision entschlossen wir uns zur lokalen Sklerotherapie. Am Folgetag sistierte die Fördermenge
komplett. Das Manöver Ultraschallgesteuert wurde ein Spülkatheter in die Lymphkollektion inguinal eingelegt und die angesammelte Lymphe vollständig drainiert. 100mg Doxycyklin (1 Ampulle à 5ml) wurde
mit 5ml Lidocain 0.5% über den liegenden Katheter instilliert. Um die optimale Verteilung des Wirkstoffes
zu gewährleisten, wurde der Patient angehalten während 60 Minuten nach Instillation häufig zwischen
liegender, sitzender und stehender Position zu wechseln. Dann wurde die instillierte Lösung möglichst
vollständig über den Katheter aspiriert, der Katheter entfernt und ein leichter Kompressionsverband angelegt.
Results: Dem therapeutischen Effekt der Sklerotherapie liegt die Entwicklung einer Entzündungsreaktion
zugrunde, die im Falle der Lymphleckage Adhäsionen und Fibrose im Bereich der verletzten Lymphgefässe induziert. Neben Doxycyclin wird in anderen Berichten Substanzen wie Bleomycin, Povidon-Jodid, Talg
oder Alkohol der gleiche Effekt zugeschrieben. Die Instillation sklerosierender Agentien in Kombination mit
externer Drainage besticht mit einer Erfolgsrate über 90%. Die pedale Lymphographie als Goldstandart
zur Darstellung von Lymphleckagen besitzt ebenfalls therapeutischen Charakter und führt in ca. 65% zur
vollständigen Versiegelung der Leckage. Selbstverständlich kommt der Prävention von postoperativen
Lymphozelen durch sorgfältige chirurgische Präparation, Verwendung von Elektrokoagulation oder korrektem, schichtweisem Wundverschluss grosse Bedeutung zu.
Conclusion: Die Behandlung der postoperativen Lymphozele durch perkutane Drainage kombiniert mit
der Instillation einer sklerosierender Substanz ist eine einfache und erfolgsversprechende Behandlung
von inguinalen, postoperativ aufgetretenen Lymphozelen und Lymphfisteln, insbesondere als Alternative
zur chirurgischen Wundrevision.
17.11
Image guided, robotically assisted, high precision drilling of osseous lesions with sensitive adjacent
structures
S. Schaeren, M. Rasmus, M. Wierwiorski, D. Bilecen, V. Valderrabano (Basel)
Objective: Within the setting of a Multifunctional Image-Guided Therapy Suite with CT scanner (University
Hospital Basel) an image guided robotic assistance device (InnoMotion by Innomedic, Germany) providing guidance for guide wires or needle insertions in accordance to trajectories planned on the basis of
intraoperative DICOM data sets was used to treat osseous lesions adjacent to sensitive joint or nervous
structures by a minimal invasive approach.
Methods: A total of 4 patients suffering from pain due to osteochondal lesions (OCL) of the distal tibia
39
(n=3) or talus (n=1) and one patient with osteoidosteoma located within the left pedicle of the 1st lumbar vertebra causing back pain were included. Guide wires were set under discontinuous image control.
Drilling was performed under guide wire guidance. Intervention results were controlled intraoperatively, if
necessary interventions were expanded until target lesions were reached (OCL) or completely extracted
as biopsies with core drill technique (osteoidosteoma). The OCL were filled with demineralized bone matrix (DBM).
Results: All interventions were primarily technically successful. All target lesions were reached. No intra-or
postoperative complications like damage of adjacent nervous or joint structures or infection appeared.
Histologically osteoidosteoma was confirmed. Long term results are not available yet.
Conclusion: Image guided robotical assistance can be successfully used to treat osseous lesions adjacent to sensitive structures with high precision. In these selected indications we showed that mechatronically supported image guidance is an essential factor allowing minimally invasive approaches.
17.12
Role expectations in a surgical team
A.P. Businger1, P. Moser2, T. Manser3, F. Gambazzi1, A. Kuhrmeier4, M. Furrer2 (1Basel, 2Chur, 3Zürich, 4Lugano)
Objective: A social role is a set of behaviors and obligations in a given social system that often is defined as an expected behavior in an individual social position. Maintaining defined social roles minimizes
uncertainty in a professional team. The development of a role presupposes a minimum amount of time
devoted to interpersonal contact, a factor often not fully developed in a surgical team because of daily
alternating teams. Fortunately, surgery has a highly developed professional culture with distinctly defined
roles. The present study investigated role expectations in a surgical team.
Methods: A questionnaire interview was utilized in a surgical team at two non-university hospitals in two
language areas (German and Italian) in Switzerland with 139 nurses, nurse assistants, and surgeons.
The mean age (standard deviation) was 35 years (15), and 48 of the 139 subjects (34%) were male.
We obtained information on age, gender, team position, and professional experience. We used the Sozialperspektivische Image Positionierung, a shortened form of the SYMLOG questionnaire, to evaluate the
professional groups’ ratings of sympathy, influence, and goal orientation.
Results: Surgeons had significantly higher influence (p < 0.001) and goal orientation (p = 0.013) than
nurses. Remarkable were the low self-assessment and peer-assessment values of sympathy for surgeons. Nurses and surgeons rated themselves higher in self-perception than the nurse assistant group.
Age, sex, professional experience, and language had no significant effect on ratings.
Conclusion: In this sample of team members, clearly defined roles did not exist. The perceived influence
and goal orientation of the surgeons could presume a claim to leadership and potentially lead to conflict
among team members. Such disparate perceived roles reveal areas for improvement that could optimize
performance.
17.13
Type III open chopart fracture-subluxation: a case report
A. Isaak, C. Geppert, N. Renner (Aarau)
Objective: Chopart fracture-subluxations are rare & their discussion in the literature is limited. Increasing
numbers of midtarsal fracture-subluxations have recently been reported as a result of more high-energy
traumas. We report this case due to its complexity & the good clinical result.
Methods: Case report. In July 2007, a 17-year-old inebriated man suffered a scooter accident. The exact
mechanism of injury remains unknown. He was immediately referred to the Kantonsspital Aarau. Physical examination & Rx including CT revealed a type III open, medio-dorsal fracture-subluxation of the
right talonavicular & calcaneocuboid joints & a comminuted fracture of the calcaneus & non-dislocated
fractures of the talus, navicular & cuboid. No neurovascular deficits or signs of compartment syndrome
were noted. Irrigation & débridement of the heel pad avulsion injury & the multiple soft tissue lesions were
performed. Further inspection showed an almost complete rupture of the plantar aponeurosis & a large
defect of the plantar musculature. The peroneus brevis tendon was not damaged. Open reduction of the
midtarsal joints was achieved by traction & pronation & secured by a tibiotarsal external fixation. The skin
defects were closed by Epigard, the aponeurosis was adapted loosely. Postoperative CT scans of the right
foot showed anatomical reduction of the fractures. Immobilization by external fixation was continued as
definite treatment. The reconstructive phase included several wound-vac-treatments & subsequent skin
closure by mesh-grafts. 6 wks post trauma the external fixation was extended by a metatarsal V Schanzscrew. 8 wks post trauma the patient developed a pin-track infection which was treated by antibiotics &
removal of the external fixation. The patient then started physiotherapeutic treatment & partial weightbearing. The follow-up examinations at 8, 13, 16 & 27 wks showed an excellent clinical result. 13 wks
post trauma, the patient had particially (50%) returned to work as a postman. At the 27 wk follow-up
examination, the patient had no weight-bearing pain & no dysfunction of the right foot.
Results: Discussion. The mid-tarsal joint, including the talonavicular & calcaneocuboid joints are functionally closely related to the subtalar & Lisfranc joints. The joint lies in a plane transverse to the medial
& lateral longitudinal arches of the foot. The medial side is more dynamic & mobile, whereas the lateral
side is relatively rigid & stable. Main and Jovett (1), who reviewed 71 mid-tarsal joint injuries, established
5 groups according to the direction of the deforming force & determined features affecting prognosis.
Richter et al (2) reported 110 major injuries involving Chopart joint-dislocations, of which 60 were Chopart
fracture-subluxations. The authors postulated, that prompt & accurate open reduction of Chopart fracturedislocations improved clinical outcome. As in our case report, the injury was a Gustilo type III fracture
with extensive soft-tissue damage. This greatly increases the risk for infection & possible amputation (3).
Despite early comprehensive management of open injuries of the midfoot, the outcome has a high morbidity (4). Intra-articular fractures, despite correct reduction, carry a poor prognosis for early arthrosis (5).
Conclusion: Early open & anatomical reduction, external fixation & subsequent reconstructive soft-tissue
surgery are recommended in treating type III open Chopart fracture-subluxation.
40
17.14
Inguinal endometriosis mimicking groin hernia
F. Pugin, P. Bucher, S. Ostermann, Ph. Morel (Genève)
Objective: Extraperitoneal endometriosis is a rare condition that can be confused with groin hernia when
located in the inguinal area.
Methods: We report three cases of inguinal endometriosis presenting in young female patients incidentally discovered during surgery for suspected incarcerated groin hernia. Diagnosis of endometriosis was
suspected during operation and confirmed histologically in all.
Results: Two patients presented with clinically incarcerated inguinal hernia, for which endometriosis of
the extraperitoneal part of the round ligament was suspected per-operatively. Complete round ligament
resection and hernia mesh repair were performed. One of these patients underwent a diagnostic laparascopy, which showed associated diffuse peritoneal endometroisis. In one patient, a cystic endometriotic
mass was found as part of an incarcereted femoral hernia sac. Complete resection of the sac and endometriotic mass was performed associated with mesh repair of the femoral hernia. No inguinal endometriosis recurrence was observed in these patients.
Conclusion: Inguinal endometriosis is often confused with incarcerated groin hernia. Surgical excision is
curative if the entire lesion is removed and the associated hernia repaired.
17.15
CPR-associated liver injury: a case report and review of the literature
B. Schnueriger1, R. Inglin2, D. Inderbitzin1, D. Candinas1 (1Bern, 2Fribourg)
Objective: Although early cardiopulmonary resuscitation (CPR) is associated with increased survival of
sudden cardiac arrest victims, it may also result in miscellaneous injuries.
Methods: We are presenting a patient recently treated at our institution and reviewed the literature concerning CPR-associated liver injury.
Results: A 53-year-old man was admitted in stable conditions to the emergency department following
out-of-hospital cardiac arrest and immediate resuscitation by chest compressions by lay bystanders. A recurrent acute thrombotic occlusion of a right coronary artery stent was found in the emergence coronary
angiography (PTCA) and could be revascularized. Systemic thrombolysis (Acetyl-salicyl-acid, Clopidogrel, Heparin) was performed, and therapeutic hypothermia was induced. Four hours after admission, the
patient deteriorated with sudden hypotension and abdominal tenderness. Bedside abdominal ultrasound
revealed free liquid within the abdominal cavity. An arterial blush from a left sided minor liver laceration
was provided by a contrast enhanced computed tomography (CT) scan and an immediate selective angioembolisation of a segmental left hepatic artery was successfully performed. CT scans three and seven
days later showed no evidence of recurrent bleeding. The patient was discharged after 19 days in good
condition.
Conclusion: The benefit of immediate and continuous chest compression by far outweighs the infrequent
and treatable complications of liver injury after CPR. But sudden hypotension or dropping haemoglobin/
haematocrit levels after out-of-hospital resuscitation should trigger suspicion of left lobe liver injury. Resuscitation-associated liver injuries are infrequent and often associated with compromised haemostasis
due to systemic thrombolysis and therapeutic hypothermia. With that, emergency surgery is strongly
complicated and a selective angiographic embolisation may be the intervention of choice.
17.16
Medial tibial stress syndrome associated with clubfeet in a hunter
P. Potocnik, Y.P. Acklin, C. Sommer (Chur)
Objective: Medial tibial stress syndrome is an exercise induced pain syndrome along the posteromedial
border of the tibia. It has been reported to occur commonly among athletes, dancers and military recruits.
It has also been found, that a pronated foot type increases the risk of this syndrome. Once diagnosed,
surgery can significantly reduce the associated symptoms. We report our first case with this to us until
now unknown syndrome.
Methods: A 28 years old man with the history of a bilateral clubfoot surgery in childhood presented a
medial stress related pain in both lower limbs after days of hiking and hunting in the mountains. Due to
the clinical inflammatory signs and elevated C-reactive protein level, a bilateral soft tissue infection was
initially diagnosed and treated with antibiotics as well as NSAID. Since this treatment was unsuccessful,
further imaging (MRI, Sonography) followed. An edema of the subcutaneous fat and periosteum posteromedial of the lower leg was shown. Due to an atrophic aspect of the soleus muscle, we explored
this compartment of the impaired leg by fasciotomy to exclude a muscle necrosis after exercise induced
compartment syndrome.
Results: Only four days after surgery the symptoms diminished on the operated as well as the not operated leg and the patient was discharged. At the one month follow up, the patient remained pain free.
Conclusion: Medial tibial stress syndrome was for us an unknown surgical entity also already described
in the literature. It can be misdiagnosed as local infection or exercised induced compartment syndrome.
Mild symptoms can be treated conservatively; severe cases should be operated with fasciotomy of the
compartements.
17.17
The influence of chemotherapy on SYT/SSX2 fusion transcripts of t(X;18) translocation and cytotoxicity
in the recurrence of a primary intraabdominal sarcoma
N. Kalak, T. Steffen, C. Öhlschlegel, J. Lange, M. Zünd (St. Gallen)
Objective: Synovial sarcoma mainly occurs in the soft tissue and is localized in para-articular regions. Extraarticular synovial sarcomas have been reported in head and neck, mediastinum, lung, retroperitoneum
and in the skin. The gastrointestinal tract is rarely reported as primary site of synovial sarcomas. Hallmark
of synovial sarcomas is the tumor specific chromosomal translocation t(x;18) resulting in the expression
of the SYT/SSX fusion transscript. Detection of this chromosomal translocation is the diagnostic tool to
identify synovial sarcomas in extra-articular localizations. Synovial sarcomas with the t(x;18) translocation can also be detected immunohistochemically with antibodies against cytokeratins, EMA vimentin or
bcl-2. However, these methodes are not very specific. It is still unclear whether chemotherapy has any effect on synovial sarcomas with the t(x;18) translocation. We report a case of a primary synovial sarcoma
of the duodenum with SYT/SSX-2 type of the t(x;18) translocation.
Methods: The synovial sarcoma was resected and the patient received an adjuvant chemotherapy with
gemzar and taxotere. 8 months after resection the patient experienced a histological proven locoregional recurrence of the synovial sarcoma in the duodenum. After 2 cycles of neoadjuvant chemotherapy
consisting of adriblastin and ifosfamid, PET-CT restaging showed no increased uptake indicating a good
response to chemotherapy. The tissue sample of the locoregional recurrence was examined histopathologically and immunohistochemically. Furthermore, fluorescence in situ hybridization (FISH) and reverse
transcriptase polymerase chain reaction (RT-PCR) were performed to detect the t(x;18) translocation.
Results: Histopathological examination of the resected tissue showed spindle cell myxoid tumorinfiltration
of the duodenal wall. Compared to the biopsy tissue sample taken before the neoadjuvant chemotherapy,
a significant decrease in the cellular density was observed. The biopsy tissue showed a highly cellular
mesenchymal tumor whereas the resected tissue showed significant myxoid stromal changes. The
resection specimen showed a weak immunohistochemical staining for EMA and CD99, strong staining
for bcl-2 and vimentin but no staining for CD34, S-100 and desmin. Proliferation index MiB-1/Ki-67 was
increased by 20 to 50%. Translocation t(x;18) of the SYT/SSX-2 type could be detected by FISH and RTPCR.
Conclusion: Despite neoadjuvant chemotherapy with ifosfamid/adriblastin SYT/SSX-2 type fusion transcripts of translocation t(x;18) could still be detected by FISH and RT-PCR in the resected recurrent locoregional tumor tissue. Which shows that neoadjuvant chemotherapie is not sufficient to destroy the tumor.
This points out the importance of surgical radicality in resection of pretreated locoregional recurrence of
synovial sarcoma of the duodenum.
17.18
Invertierende bilaterale Achternaht der Rectusscheiden nach Platzbauch mit Zerstörung der Linea alba
– Überlegungen zu einer neuen Technik
U. Dietz, I. Kuhfuss, A. Thiede (Würzburg/DE)
Objective: Die Inzidenz des Platzbauches nach grossen abdominalchirurgischen Eingriffen ist mit 1-3%
und hoher Morbidität und Mortalität ein bedeutendes Problem. Die häufigsten technisch bedingten Ursachen sind eine zu hohe Nahtspannung, das ungenügende Fassen der Faszienränder (<1cm), die Missachtung des Fadenlänge-Wundlängeverhältnisses, der Knoten- oder Nahtbruch sowie das Ausreissen
der Naht aus dem Gewebe. Nach sekundärem Bauchdeckenverschluss entwickelt die Hälfte der Patienten im Verlauf von einem Jahr einen Narbenbruch. In dem vorliegenden Poster wird eine Nahttechnik
vorgestellt, um die anatomische Rekonstruktion der Medianlinie zu ermöglichen.
Methods: Exemplarisch wird der Fall eines Patienten demonstriert, der nach vorangegangener Sepsis bei
Polyarthritis eine perforierte Sigmadivertikulitis entwickelt hat. Nach Sigmaresektion kam es am 6. postoperativen Tag zu einem Platzbauch. Bei der Revision zeigte sich ursächlich hierfür, dass die Linea alba
durch Nekrose zerstört war. Unter Berücksichtigung der Morphologie der Kollagenfasern der Linea alba
und der Rectusscheiden bedeutet der Verschluss eines solchen Abdomens eine grosse Herausforderung.
Die Rekonstruktion erfolgte durch eine invertierende bilaterale Achternaht beider Rectusscheiden in Einzelknopftechnik in Kombination mit Entlastungsinzisionen und Netzverstärkung in Sublay-Technik.
Results: Der Verlauf der ersten beiden postoperativen Jahre war unauffällig, der Patient hat bis dato weder klinisch noch sonographisch einen Narbenbruch entwickelt und ist wieder voll in sein Arbeitsleben
integriert. Die aktuelle Kasuistik der Chirurgischen Klinik I der Universitätsklinik Würzburg beträgt 16 Patienten.
Conclusion: Die Ergebnisse nach 2 Jahren ergaben, dass bei den mit dieser Technik operierten Patienten
keinen nennenswerten Komplikationen, insbesondere kein Narbenbruch aufgetreten ist. Es wird sich im
Verlauf zeigen, ob diese Technik die Narbenhernienrate nach sekundärem Bauchdeckenverschluss bei
Platzbauch auch dauerhaft reduzieren kann.
Research
19
19.1
Increased frequency of regulatory T cells in tumor-infiltrating lymphocytes in colorectal cancer patients
predicts improved survival
D.M. Frey, R.A. Droeser, C.T. Viehl, I. Zlobec, C. Kettelhack, L. Terracciano, L. Tornillo (Basel)
Objective: Tumor-infiltrating lymphocytes (TILs), the primary immune component infiltrating solid tumors,
are considered to be a manifestation of the host antitumor reaction. Recent results have shown a correlation between survival and frequency of TILs in colorectal cancer patients. There is accumulating evidence
that the specific type of immune cells, rather than their sheer quantity, governs the host-versus-tumor
immune response. Regulatory T cells (Tregs) seem to be a detrimental factor in the generation of hostversus-tumor immunity via suppression of tumor-specific effector T-cell responses and development of
immune tolerance to neoplastic cells. In most of the solid tumors studied so far, accumulation of Tregs
predicts a striking reduction of patient survival. However, paradoxically, increased Tregs were found to
be associated with improved prognosis in lymphoma patients. Although increased frequency of Tregs in
peripheral blood and TILs of colorectal cancer patients is well documented, it remains unclear whether an
increased frequency of tumor-infiltrating Tregs influence clinical outcome of CRC patients. To address this
question, we analyzed the infiltration of CRC by FOXP3 positive Tregs and investigated whether there is a
correlation to disease stage and survival of CRC patients.
Methods: Immunohistochemistry for CD3, CD8 and Tregs was performed on a tissue microarray (TMA)
of a total of 1420 CRC samples. Tregs were stained with an antibody for FOXP3, a key control molecule
for Treg development and function and excellent marker for the study of Treg. Cut-off scores for positive
FOXP3, CD8 and CD3 expression were obtained by means of ROC curve analysis. The association of
FOXP3 and clinico-pathological features was evaluated using logistic regression. 10-year survival time
was analyzed by the Kaplan-Meier method and log-rank test while multivariate analysis was carried out
with Cox proportional hazards regression.
Results: Positive FOXP3 was significantly associated with early T stage (p-value < 0.001), absence of
lymph-node involvement (p-value = 0.004), low tumor grade (p-value = 0.027) and absence of vascular
invasion. In univariate analysis, positive FOXP3 (p-value < 0.001), CD8 (p-value < 0.001) and CD3 (p-value < 0.001) expression were associated with significantly improved 10-year survival time. In multivariate
analysis adjusting for known prognostic factors, FOXP3 was found to be independently associated with
survival time (HR (95%CI) = 0.79 (0.66-0.93); p-value = 0.006). CD8 positivity was found to have strong
independent prognostic value (HR (95%CI) = 0.74 (0.62-0.88); p-value < 0.001) while CD3 positivity did
not (p-value = 0.157). Significant positive correlation between all three cell types was found (FOXP3/CD3
0.33 [p < 0.001]; FOXP3/CD8 0.48 [p < 0.001]; CD8/CD3 0.49 [p < 0.001]).
Conclusion: Strikingly, our analysis of 1420 CRC samples shows that intratumoral density of Tregs predicts a significantly better outcome. Determining the ratio of FOXP3 Tregs and CD8 T cells in TILs may not
only predict which patients are at highest risk of recurrence, but also serve to identify patients with tumor
who may benefit by future immunotherapies targeting this pathway.
19.2
Development of a cell encapsulation approach for human anti-tumor immunotherapy
F. Schwenter1, S. Zarei1, P. Luy1, N. Bouche2, Ph. Morel1, P. Aebischer2, N. Mach1 (1Genève, 2Lausanne)
Objective: Active specific anti-tumor immunotherapy represents an attractive alternative to chemotherapy
and radiotherapy for the treatment of malignancies. Promising results have been reported with whole
tumor cells genetically engineered to secrete immunostimulatory molecules such as granulocyte-monocyte colony-stimulating factor (GM-CSF). Nevertheless extreme variation in cytokine release limit clinical
relevance, as reproducibility and standardization cannot be achieved. The aim of this study was to develop a novel immunization strategy using macroencapsulated cells. This new approach should lead to
the standardized and reproducible release of GM-CSF at the vaccination site, a key parameter for clinical
implementation.
Methods: The cell line used in this model is the human erythroleukemia cell line K562 transfected with
the human GM-CSF cDNA and then selected for high, stable and sustained GM-CSF secretion. K562 cells
producing GM-CSF (K562-GM) were enclosed in 1 cm-long capsules at various densities. Capsules were
previously tested for physical parameters such as their elongation and breaking related to the traction
force. K562-GM-containing capsules were studied according to their secretion ability and histology at
various time points in native conditions or after freezing and thawing, and irradiation.
Results: K-562-GM cells are able to secrete 18 Î_g GM-CSF/106 cells/24h. When applying a growing traction force, empty capsules presented comparable results in term of elongation values in native conditions,
after freezing and thawing or after irradiation. Capsules containing 105 K562-GM cells were maintained
in culture medium or frozen at 1 or 3 days after cell loading. GM-CSF secretion tests were done at various
time points after capsules thawing and compared to the non frozen control group. The frozen capsules
showed comparable results after 8 days in culture with 990Â±374 ng GM-CSF/capsule/24h. At the same
time, control capsules secreted 1393Â±27ng GM-CSF/capsule/24h. Capsules frozen 1 day after the loading showed lower secretion ability until day 8 than the group frozen after 3 days. At histological analysis,
all groups showed high cell survival potential even after 25 days, with the apparition of slight central
necrosis from day 8 for the control group and the group frozen after 3 days and from day 15 for the group
frozen after 1 day. When irradiated, K562-GM-CSF capsules showed a decrease of secretion and increase
of cell mortality over a period of 14 days.
Conclusion: In conclusion, this study indicates that encapsulated K562-GM-CSF cells are able to secrete
high level, constant and reproducible amount of GM-CSF over a period of 25 days even after freezing /
thawing procedures. Such results are very promising for future application of this strategy using encapsulated allogeneic cells secreting immunostimulatory molecules for anti-tumor immunotherapy.
19.3
Clinical grade influenza virosomes are highly efficient vectors for melanoma immunotherapy
M. Adamina1, R. Schumacher1, D.M. Frey1, C. Feder-Mengus1, W.P. Weber1, P. Zajac1, R. Rosenthal1,
R. Zurbriggen2, M. Amacker2, D. Oertli1, G. Spagnoli1, M. Heberer1 (1Basel, 2Bern)
Objective: Clinical responses were obtained in 2 phase I/II melanoma immunotherapy trials. In preparation of a phase III trial, innovative virosomal vectors were developed and extensively refined prior achievement of a standardized virosomal vaccine. Strong adjuvant properties, together with stabilization of the
virosomes and definition of the optimal vector-to-payload concentration were required, while responding
to the regulatory constraints of an industrial production. We report in vitro efficacy data of an off-the-shelf,
patented therapeutic melanoma vaccine of clinical grade.
Methods: Freeze-dried preparations of Influenza virosomes incorporating hemagglutinin, phosphatidycholine, phosphatidylethanolamine and cholesteryl-N-trimethylammonioethyl carbamate chloride were
synthetized. The virosomal formulation (TIRIV) was reconstituted in NaCl 0.9% by admixing the lyophilized
melanoma epitope L27-Mart126-35 (M) to the virosomes. Control liposomes (CL) of similar composition
but devoid of hemagglutinin were synthetized. Proliferation was measured by thymidine incorporation.
Gene expression was measured by real-time PCR and was correlated to protein secretion by ELISA. Cells
were phenotyped by flow cytometry analysis. Induction of melanoma specific cytotoxic T lymphocytes
(CTL) was assessed by cytotoxicity assays. Results were confirmed on a panel of 8 healthy donors.
Results: Different virosome-to-epitope concentrations were assessed: a TIRIV concentration of 1:400 with
41
0.25ug/ml of M retained full antigenic power and showed no cell cytotoxicity. TIRIV triggered a marked
proliferation of CD4+ but not of CD8+ T lymphocytes, whereas CL and M were ineffective: 93’765 cpm Vs
751 and 546 cpm, respectively (p=0.005). No proliferation was observed upon stimulation of fetal cord
blood, whereas proliferating adult CD4+ T lymphocytes were CD45RO+, consistent with a memory phenotype. IL-4 was not detected in stimulated cultures, whereas TIRIV stimulation increased the gene expression of IFN-_ and its strong secretion: 1278 pg/ml for TIRIV Vs absent secretion for CL and M (p<0.001).
Finally, CXCR3 was overexpressed in TIRIV stimulated CD4+ T lymphocytes, but not when stimulated with
CL: 52% Vs 11% (p<0.001), thus underlining a T helper 1 adjuvance of TIRIV. Autologous CD14+ cells
were incubated with immature dendritic cells, and stimulated twice with TIRIV, M or a control peptide: 58%
of CTL in culture specifically recognized the melanoma epitope after stimulation with TIRIV, as opposed
to 11% when stimulation was done with M (p=0.01). Similarly, TIRIV stimulated CTL showed a 5-time higher IFN-_ production than induction cultures with M (p<0.001). Undesired induction of regulatory T cells
by stimulation with TIRIV was limited to 12.7% CD4+ / Foxp3+ lymphocytes. Finally, cytotoxicity assays
showed 69% specific lysis of melanoma target cells by TIRIV stimulated cultures, as opposed to a 21%
specific target lysis for cultures stimulated with M (p=0.01). Remarkably, TIRIV lyophilisates retained their
qualities for over 6 months when conserved at 4°C.
Conclusion: This clinical grade virosomal melanoma vaccine demonstrated highly efficient and consistent immunological results while complying with the stringent requirements of an industrial production.
This crucial achievement thus allows the testing and support of a new generation of melanoma vaccines
in human.
19.4
Human hepatocellular cancer-cells survive with serotonin
C. Soll, M. Riener, W. Moritz, P.-A. Clavien (Zürich)
Objective: Serotonin, a neurotransmitter and vascular active substance, can act as a potent cellular mitogen on different cell types and is crucial for liver regeneration. Involvement in the tumour biology of lung
and prostate cancer has been described. Therefore we wanted to evaluate the impact of serotonin on
growth of hepatocellular carcinomas.
Methods: 3H-thymidin-incorporation was measured in three different human hepatocellular cancer celllines (HepG2, Huh7, Hep3B) after stimulation with serotonin (5-HT). To distinguish between proliferation
and improved survival a combined calcein/ethidium-staining was performed. Immunoblots were used to
investigate serotonin-dependent pathways leading to survival of the cell-lines. Immunohistochemistry for
the serotonin receptor HTR1B and HTR2B were performed on a tissue-micro-array from 61 patients with
hepatocellular carcinomas.
Results: 3H-thymidin-incorporation indicated an increased proliferation of serum-starved HepG2, Huh7
and Hep3B with 100 µM 5-HT compared to serum-free-media after 48h (p=0.01). Interestingly, calceinstaining shows a similar amount of living cells stimulated either with 10% serum or 100 µM 5-HT after
serum-starvation, whereas untreated cells were predominantly positive for ethidium indicating cell death.
Immunoblots revealed activation of the kinases PKC and ERK1/2 after stimulation with serotonin. Of the
61 hepatocellular carcinomas, 14% and 26% were positive for HTR1B and HTR2B, respectively, whereas
normal liver parenchyma was negative for HTR1B and HTR2B. There was a significant correlation with the
proliferation marker Ki67 (r=0.342, p=0.007) and HTR2B. Receptor-staining of HTR1B was associated
with vascular invasion of the tumor (p=0.04).
Conclusion: We conclude that serotonin acts as a survival factor for hepatocellular cancer cell lines. Furthermore, more than one-fourth of the patients with hepatocellular carcinoma were positive for HTR2B.
Hence serotonin-receptors may represent a novel target for the treatment of hepatocellular cancer.
19.5
Targeting SIRT1 for anti-tumor therapy: inhibition of SIRT1 downregulates HIF1
A. Laemmle, S.A. Vorburger, A. Keogh, V. Roh, D. Candinas, D. Stroka (Bern)
Objective: In patients with breast cancer, MT1-MMP expression was shown to predict poor overall survival
but the effect of MT1-MMP on distant lung metastasis is unknown. We studied the correlation between
cancer cell-MT1-MMP expression, staging, vascular invasion and lymph node status in 102 prospectively
collected breast cancer biopsies. We then determined the effect of cancer cell-MT1-MMP downregulation
on tumor growth, migration, vasculature invasion and distant lung metastasis in an orthotopic model of
ER-PR-HER2- breast cancer in mice.
Methods: MT1-MMP expression, tumor blood and lymphatic vasculature invasion were determined in
each breast cancer biopsy by immunohistochemistry. Staging and lymph node status were based on
clinical, radiological and anatomopathological evaluations. In the mouse model, MT1-MMP was downregulated using shRNA technology. Tumors were implanted orthotopically and the development of lymph
node and lung metastasis was assessed after 14 weeks. Cancer cell migration was determined by intravital multiphoton laser scanning microscopy of tumors implanted in our newly developed mammary fat
pad chamber.
Results: Cancer cell-MT1-MMP expression in ER-PR-HER2- breast cancers correlates with blood vessel
invasion but not lymph node metastasis. In the mouse model we show that cancer cell-MT1-MMP downregulation decreases spontaneous lung metastases without affecting primary tumor growth or lymph
node metastasis. Interestingly, MT1-MMP down-regulation reduces tumor cell migration and vascular
basement membrane degradation which limits blood, but not lymphatic, vessel intravasation.
Conclusion: Tumor-MT1-MMP could be a valuable clinical prognostic marker and a target for the prevention of vascular invasion and lung metastasis in ER-PR-HER2- breast cancer.
19.6
Blood vessel invasion and distant lung metastasis are promoted by MT1-MMP expression in triple negative breast cancers
J.Y. Perentes1, N. Satoshi2, C.M. Shaver2, I. Garkavstev2, L.M. Munn2, R.K. Jain2, Y. Boucher2 (1Lausanne,
2
Boston/US)
No prepublication before publishing
19.7
Isolated lung perfusion versus intravenous drug administration: comparison of free and liposomal doxorubicin distribution in a sarcoma model
C. Cheng, A. Haouala, T. Krueger, F. Mithieux, J. Ballini, S. Peters, S. Andrejevic-Blant, L.A. Decosterd, H.B.
Ris (Lausanne) Discussant: G. Spagnoli (Basel)
Objective: Isolated lung perfusion (ILP) with free and liposomal-encapsulated doxorubicin (Liporubicin™)
was compared to intravenous (IV) drug administration with respect to drug uptake and distribution in rat
lungs bearing a sarcoma tumor.
Methods: A single sarcomatous tumor was generated in the left lung of 40 Fischer rats, followed 10 days
later by left-sided ILP (n=20) or IV drug administration (n=20); for each doxorubicin formulation at a drug
dose of 100 µg (n=5) and 400 µg (n=5). In each perfused lung, the drug concentration was assessed in
the tumor and in three areas of normal lung parenchyma by HPLC.
Results: ILP and IV resulted both in a consistently lower drug uptake in tumors than in lung parenchyma
for both doxorubicin formulations and both drug doses applied. For free doxorubicin, ILP resulted in a
higher drug uptake in the lung and the tumor compared to IV for each drug dose; the tumor to normal
tissue drug ratio was similar for ILP and IV at 100 µg (0.27±0.1 vs 0.39±0.1) (p=0.11) and higher for ILP
at 400 µg (0.67±0.2 vs 0.27±0.1) (p=0.02). For Liporubicin™, ILP and IV resulted in a similar drug uptake
in the lung and the tumor for each drug dose but the tumor to normal tissue drug ratio was higher after ILP
for both drug doses, without reaching statistical significance (0.52±0.5 vs 0.28±0.1 for 100 µg, p=0.28;
0.54±0.2 vs 0.41±0.1 for 400 µg, p=0.27).
Conclusion: The tumor to normal tissue drug ratio was higher after ILP than after IV drug administration
for both doxorubicin formulations. The best tumor drug uptake (36.9±10.4 µg/g) and tumor to normal
tissue drug ratio (0.67±0.2) were obtained with ILP and 400 µg of free doxorubicin.
19.8
Modulation of immunogenicity of viral cancer vaccine
N. Raafat1, C. Feder-Mengus1, C. Groeper1, R. Rosenthal2, M. Adamina1, G. Spagnoli1, P. Zajac1 (1Basel,
2
Lausanne)
Objective: Although many reports have highlighted the potential of poxviral vectors as recombinant vaccines, their immunogenicity can also be a major drawback. Indeed, immunodominant vector-specific CTL
response could limit the effectiveness of recombinant poxviruses especially in cancer immunotherapeutic strategies which often require multiple rounds of vaccine stimulations. To balance this effect, powerful
heterologous prime-boost strategies or immuno-modulation of vector specific responses are required.
We aim at decreasing CTL responses against Vaccinia Virus by diminishing the viral epitope MHC class-I
restricted presentation from infected cells without affecting the presentation of recombinant TAA epitopes
encoded by minigenes or MHC class-II presentation of viral entities. This approach should simultaneously
decrease epitope competition and the CD8 anti-vector responses. ICP47 protein (encoded by US12 gene
from HSV-I) has been shown to interact with Transporter of Antigen Processing (TAP) protein thereby inhibiting peptide transport to the Endoplasmic Reticulum. This peptide blockade prevents MHC-I loading and
surface presentation. We anticipated that in antigen presenting cell infected with recombinant vaccinia
virus expressing US12 gene, the generation of epitopes derived from viral proteins should be blocked. In
contrast, recombinant ER-targeted vaccine epitopes should not be affected and their overall immunogenicity may be increased.
Methods: Herpesvirus US12 gene was introduced into Vaccinia virus wild type as well as the rVV expressing the ER-Mart27-35, a melanoma associated HLA-A2 restricted epitope. Effect on MHC-class I and
other surface molecules from infected cells (using non replicating virus) was characterized by antibody
staining and FACS analysis. Human T-lymphocyte were stimulated in vitro with autologous CD14+ cells
infected with US12-rVV, M-US12- rVV or control virus. Proliferation of specific CD8+ and CD4+ for viral
proteins and the recombinant epitope were monitored by MHC-multimer and IFNg intracellular staining.
Results: US12-rVV demonstrated MHC class-I downregulation. Kinetic analysis of MHC class-I downregulation indicated that this effect become most visible after 16-24h of infection. In HLA-A2 positive cell
lines , HLA-A2 downregulation with US12-rVV was partially compensated by presence of ER-Mart peptide
in M-US12-rVV The absence of effect of US12-rVV on other surface molecules CD44, CD80 and MHC
class II demonstrates that ICP47 effect is specific for MHC class-I molecule. Preliminary tests seem to
confirm that CD8+ responses against viral epitopes (processed from vaccinia vector) are diminished
when primed with US12-rVV.
Conclusion: Recombinant vaccine expressing the HSV-US12 gene confirmed a diminished class-I recognition of native proteins from the viral vector. While helper-class-II properties should be conserved, this
type of vector could thereby have a stronger immunogenic potential toward the recombinant ER-targeted
class-I epitope. Such reagent could become of high relevance especially in multiple-boost vaccine protocol required in cancer immunotherapy.
19.9
Serotonin improves regeneration in the aging mouse liver
K. Furrer, Y. Tian, W. Jochum, C. Soll, A.G. Bittermann, J.H. Jang, R. Graf, P.-A. Clavien (Zürich)
Objective: To test whether serotonin improves regeneration in the aging liver by modifying sinusoidal epi-
42
thelial cell (SEC) structure. The increasing age of patients with liver disease requiring surgery leads to
more complications related to failure of regeneration. Previous work demonstrated that the aging liver has
a reduced capacity to regenerate after major tissue loss. In addition to molecular changes, it has been
observed that the sinusoidal structure is severely affected in older individuals. A loss of fenestration in the
SEC might reduce the flow of blood components and soluble mediators into the space of Disse resulting in
impaired signalling. Serotonin has recently been implicated in the early process of regeneration in young
mice. We therefore hypothesize that serotonin may influence fenestration and propagate access to the
parenchyma after tissue loss.
Methods: N=5 per each group of young (7-8 weeks) and old mice (2 years) underwent 70% partial hepatectomy. RNA was isolated for expression analysis. Tissue was harvested to assess markers of proliferation (Ki67, PCNA) and for scanning electron microscopy at four different time points: 24hr, 48hr, 96hr and 7
days. A serotonin receptor agonist, DOI, was used to pretreat mice two days before hepatectomy.
Results: In contrast to young mice, the SEC of old mice exhibited few fenestrae. Consistent with these
changes, liver regeneration was impaired in old mice. During regeneration, the expression of serotonin
receptor HTR 2A and 2B mRNA at 48hr was highly increased in young but not old livers (p<0.0004 and
p<0.001, respectively). Pre-treatment of old mice with a serotonin receptor agonist significantly increased
the number of fenestrae and their size of SEC, similar to the young phenotype. Subsequently, hepatectomy
in DOI treated old mice disclosed improved regeneration as demonstrated by increased numbers of proliferating hepatocytes (e.g. PCNA at 48hr: 15.3 vs. 7.2). Furthermore, these animals had a better survival
after hepatectomy (p<0.04, 95% CI 1.575 to 2.425, 80 vs. 36% respectively)
Conclusion: Serotonin improves regeneration in old mice by increasing SEC fenestration. Pharmacological targeting of serotonin receptors in the liver may provide a novel approach to improve surgical interventions in the aging population.
Video
21
21.1
Laparoscopic diaphragmatic plication for diaphragmatic elevation due to phrenic nerve palsy
C. Stathakis, B. Gloor, D. Inderbitzin, D. Candinas (Bern)
Objective: Diaphragmatic eventration due to iatrogenic phrenic nerve palsy secondary to thoracic surgery
may induce significant morbidity and decreased quality of life. Patients present with a variety of symptoms
such as respiratory distress, reduced efficiency or abdominal pain. The treatment of choice for symptomatic phrenic nerve palsy remains controversial. Most publications describe an open thoracic approach for
surgical plication of the paralyzed diaphragm. Open thoracic, but also thoracoscopic techniques usually
require single-lung ventilation. Secondary to thoracic surgery, local adhesions may be present. Only few
reports of minimally invasive techniques (thoraco- or laparoscopic) for the treatment of phrenic nerve
palsy have been published to date. The video shows a laparoscopic approach of treating a diaphragmatic
eventration using a previously not described technique.
Methods: A 48-year old male patient with a 2-year anamnesis of epigastric pain, intermittent nausea,
diarrhea and loss of efficiency, was referred to our institution. In the medical history, a thymectomy had
been performed 25 years ago. A cholecystectomy because of gallbladder motility dysfunction 16 months
prior to our intervention had not induced an amelioration of the symptoms. Radiographic examinations
revealed an elevation of the left hemidiaphragm (level th 5) with herniation of the stomach and parts of the
bowel into the subphrenic space. A fluoroscopic study showed a paradoxal motion of the midriff. Thus, a
diaphragmatic plication was planned by means of a minimally invasive abdominal approach.
Results: Four working ports (2 x 5 mm, 2 x 12 mm) are placed in the upper abdomen. The patient is
brought into a reversed Trendelenburg position, and the upper abdomen is explored. The herniated organs
are released out of the subphrenic space. Retention stitches are placed in the elevated diaphragmatic
dome. By extracorporal traction on these sutures a diaphragmatic fold is created. This fold is used for the
plication by applying non-resorbable U-type sutures at the base of the fold. An additional fixation of the
stomach to the abdominal wall is done to prevent it from slipping back up into the diaphragmatic dome.
In order to examine the result and to exclude an injury to the left lung, a thoracoscopy under bilateral
ventilation is performed, using new equipment. A pleural drainage tube is left in place. Clinical follow-up
at one year and a chest x-ray reveal substantial amelioration of the patient‘s symptoms and a left hemidiaphragm at the level of th9/10.
Conclusion: Laparoscopic diaphragmatic plication for diaphragmatic elevation due to phrenic nerve
palsy avoids the need of single-lung ventilation and circumvents the problem of intrathoracic adhesions
caused by prior thoracic surgery. This video demonstrates the feasibility and safety of this surgical treatment of complicated phrenic nerve palsy.
accessed 10 times and a total of 65’ 200 ml of fluid was drained. By the end of the forth week, pleural
effusions diminished, systems were controlled for permeability and chest x-rays confirmed absence of
effusion.
Conclusion: Implanted port systems for refractory ascites and pleural effusions avoid morbidity and the
patient’s anxiety related to repeated puncture-aspiration. Large catheter diameter allows an easy and fast
drainage of large volumes. Subcutaneous location of port system allows an entire integration, giving the
patient a total liberty in daily life between two sessions of drainage. This patient-friendly technique may be
a treatment option in case of failure of other techniques.
21.3
A minimal invasive surgical approach to treat an iatrogenic cervical thoracic duct fistula
P. Stengel1, J. Michel1, J. Robert2, B. Egger1 (1Fribourg, 2Genève)
Objective: In this video we show the re-intervention in an 81-year old woman who underwent previously
thyroid and left modified neck dissection for thyroid cancer. The follow-up after this intervention was initially uneventful. However, three weeks later the patient developed a symptomatic left and basal cervical
lump containing chyle (diagnostic puncture). A 2-months conservative treatment with repeated paracentesis and diet regimen failed. Reappearance of a chyle collection was noted twice 5 to 6 days after
drainage. A high output fistula was considered and the decision to proceed with a thoracic duct ligation
by thoracoscopy was taken. The postoperative course remained then uneventful with no evidence of a
recurrence after a 3-months follow-up period.
Methods: –
Results: –
Conclusion: Chyle leakage and left cervical lymphocele caused by intraoperative lesions of the thoracic
duct is a rare complication, which are reported in 1-6% of the patients after neck surgery. Reasons are
often due to wide anatomical variations and the thin transparent wall of the duct, making its recognition
difficult. There are multiple surgical and interventional treatment options described in the literature. Direct
emobilization of the duct by interventional radiologists seems to be an interesting but painful alternative
to surgery, which is, however, not yet well established. Nevertheless, the initial treatment of this complication is always a conservative one with drainage of the chyle, compression of the site (if tolerated) and
initialisation of a low fat diet regimen. If these conservative matters fail a surgical re-intervention has to be
considered. Many surgical procedures directly at the side of the fistula have been proposed. Alternatively
ligation and obliteration of the thoracic duct in the upper abdomen or thoracic cavity have been described.
In this video we show an interesting minimal invasive and easy technique of a thoracic duct ligation by
thoracoscopy to treat the high output chylous fistula after previous neck dissection. This interesting and
well tolerated method, which first has been described by Graham et al (Ann Thorac Surg 1994) avoids the
challenging local and cervical re-operation.
21.4
Laparoskopischer mesh-verstärkter repair eines up-side down stomach mit Frührezidiv
H.J. Larusson, U. Zingg, W.R. Marti, C.T. Viehl, D. Oertli (Basel)
21.2
Objective: Der up-side down stomach ist die maximale Variante einer paraösophagealen Hernie. Es
kommt zur vollständigen Verlagerung des Magens in den Thorax, wobei eine grosse hiatale Bruchlücke
vorherrscht. Die chirurgische Therapie des up-side down stomach beinhaltet die Reposition des Magens
und des Bruchsacks, der Verschluss der hiatalen Lücke, u.U. mit Verstärkung eines Netzes sowie die
Pexierung des Magens entweder mittels direkter Naht oder mittels einer Fundoplikatio. Mögliche postoperative Komplikationen umfassen neben den üblichen chirurgischen Frühkomplikationen sowie den
fundoplikatio-spezifischen Komplikationen auch eine Rezidivrate bis 42%.
Methods: Wir präsentieren ein Video mit der laparoskopische Versorgung eines up-side down stomach
mittels Magenreposition, Cruroraphie, Hiatoplastik mit Parietex Composite Netz und Fundoplikatio sowie
des Folgeeingriffes bei Frührezidiv.
Results: Eine 71-jährige Patientin tritt mit up-side down stomach zur elektiven laparoskopischen Versorgung ein. Bei anamnestisch Refluxbeschwerden wird die Indikation zur zusätzlichen Fundoplikatio
nach Nissen gestellt. Der Eingriff verläuft problemlos und der initiale postoperative Verlauf gestaltet sich
unauffällig. Der Gastrografinschluck am 3. postoperativen Tag zeigt normale anatomische Verhältnisse
sowie einen guten Abfluss. Ab dem 5. postoperativen Tag klagt die Patientin über zunehmende Schluckbeschwerden und thorakale Schmerzen. Daraufhin wird eine abdomino-thorakale CT-Untersuchung
veranlasst, welche eine erneute Luxation des Magens in den Thorax zeigt. Die Indikation zur Revision
wird gestellt. Nach initialer Laparoskopie muss aufgrund der Adhaesionen auf ein offenes Verfahren gewechselt werden. Nach Reposition des mit der Fundoplikatiomanschette hernierten Magens erfolgt nach
Lösung derselben eine Collis Gastroplastie, sowie eine erneute Fundoplikatio nach Nissen mit ventraler
Gastropexie.
Conclusion: Frührezidive sind auch nach Hiatoplastik mit Mesh möglich. Gründe dafür können eine ungenügende Fixation des Netzes an den Crura oder ein zu kurzes intraabdominales Ösophagussegment mit
resultierendem kranialen Zug sein.
Management of malignant pleural effusion and ascites by a triple access large diameter catheter port
system
I. Inan, S. De Sousa, P.O. Myers, B. Bouclier, P. Dietrich, Ph. Morel (Genève)
21.5
Objective: Pleural or peritoneal effusions (ascites) are frequent in terminal stage malignancies. Medical
management may be hazardous.
Methods: A 60-year-old man, known for a multimetastatic malignant melanoma, presented refractory
ascites as well as bilateral pleural effusions. Medical treatment failed, bilateral pleural aspiration and paracentesis became necessary two to three times a week. A multi perforated large diameter silicone catheter
connected with a subcutaneous port was implanted in each cavity surgically under general anesthesia.
Surgical technique is described and illustrated in a video.
Results: Implanted systems were immediately operational. Follow up period was 41 days. Each port was
Liver hanging maneuver for major hepatectomy
N. Halkic, R. Ksontini, N. Demartines (Lausanne)
Objective: To demonstrate an advanced technique of liver hanging maneuver with retrohepatic dissection
performed by modified anterior approach. Background: Hepatectomy by anterior approach is indicated
where dorso-lateral liver mobilization is not possible. In these cases, hemostasis becomes difficult at the
deepest site of liver transsection. The liver hanging maneuver is claimed to prevent bleeding during transsection of liver parenchyma without previous mobilization of the liver. This technique is a useful option
during right hepatectomy for large tumors where liver mobilization is difficult, for example because of
43
adhesions and an anterior approach is required, or in living donor liver transplantation as parenchymal
transsection is usually performed prior dividing the feeding and draining vessels of the graft.
Methods: To performe a liver hanging maneuver, a tape is placed through the retrohepatic avascular
space along the retrohepatic vena cava. This tape allows to lift the liver during parenchymal transsection.
The important and most challenging step is the dissection of the retrohepatic space with a special long
vascular clamp. The space between the right and middle hepatic veins is dissected on 2 cm downward .
The blunt dissection is carried out with a long vascular clamp, posterior to the caudate lobe on the left side
of the right inferior hepatic vein, if present. Cranially, the dissection is performed with great caution along
the middle plane of the inferior vena cava toward the space between the right and middle hepatic veins
dissected initially. A special long double curved vascular clamp (Makuuchi’s clamp) is inserted from this
space and passed through the anterior midline of the cava .After 4 to 6 cm of blind dissection the clamp
appears between the right and middle hepatic veins. A tape is seized with the clamp and passed around
the hepatic parenchyma, thus allowing to lift the entire live in order to start an anterior liver transsection..
Hanging maneuver time is realized after lifting the liver with a tape.
Results: Discussion. This “no-touch” technique is easily achievable without risk of major bleeding during
right hepatectomy . With this approach, risk of major blood loss, dissemination of malignant cells, and
positive surgical margins can be reduced. An absolute contraindication however is the tumoral infiltration
of the retrohepatic space.
Conclusion: In conclusion, liver hanging maneuver is a safe and reproducible technique demonstrated
in the present video.
21.6
Bauchwandhernien – laparoskopische Bauchdeckenrekonstruktion durch linearen Bruchlückenverschluss mit intraperitonealer Netzverstärkung
A. Zerz, G.R. Linke, J. Beck, T. Güngüz, J. Lange (St. Gallen)
Objective: Bei grösseren Bauchwandhernien mit einem Bruchlückendurchmesser > 3 cm stösst der
spannungsfreie, laparoskopische Bruchlückenverschluss an seine Grenzen. Die Bruchlücke kann laparoskopisch nicht verschlossen und die Funktion der Bauchdecke nicht wiederhergestellt werden. Bei grösseren Hernien ist das offene Verfahren daher häufig die Therapie der Wahl. Wir präsentieren ein Video
zur Veranschaulichung einer laparoskopischen Technik zur Bauchdeckenrekonstruktion durch linearen
Bruchlückenverschluss.
Methods: In Rückenlage erfolgt die Anlage eines Pneumoperitoneums mit der Veresnadel unter Berücksichtigung der Voroperation und den zu erwartenden Adhäsionen. Erneuter Punktionsversuch der Abdominalhöhle von der rechten oder linken Flanke aus. Einbringen von einem 12 mm und zwei 5 mm Trokaren
in der linken bzw. rechten Flanke (insgesamt 3 Trokare). Adhäsiolyse. Abpräparieren und Resezieren des
präperitonealen Fettgewebes im Bereich der Linea alba bis zum Xyphoid mit Darstellen der hinteren
Rektusscheide. Durchtrennen des Lig. teres hepatis. Laparoskopisch linearer Bruchlückenverschluss mit
extrakorporal geknoteter, resorbierbarer Einzelknopfnaht (2er Vicryl). Mit Hilfe einer Endoclosurenadel
sind dazu an der Haut nur 1-3 Stichinzisionen notwendig. Einbringen des Proceed (Ethicon) Netzes mit
einem oder zwei Zentralfäden mit seitlicher Überlappung des Bruchlückenverschlusses von mindestens
6 cm zu allen Seiten. Die Fixation des Netzes ist bei verschlossener Bruchlücke mit resorbierbaren Tackern
möglich.
Results: Der lineare Bruchlückenverschluss ermöglicht die Rekonstruktion der Bauchdecke, das Netz gewährleistet die Dauerhaftigkeit der Reparatur. Dadurch ist es möglich, auch grössere Bauchwandhernien
in laparoskopischer Technik zu sanieren.
Conclusion: Durch die gezeigte Technik scheint ein stabiler Bruchlückenverschluss und damit eine Rekonstruktion der Bauchdecke in laparoskopischer Technik möglich.
Visceral Surgery
23
23.1
Native ureteropyelostomy for ureteral complications after kidney transplantation
K. Lehmann, M.K. Müller, M. Schiesser, S. Wildi, P.-A. Clavien, M. Weber (Zürich)
Objective: After kidney transplantation ureteral complications are an important cause of organ dysfunction. Necrosis of the ureter occurs in the early postoperative course. Stenosis leads to hydronephrosis
and elevation of retention parameters. Reflux to the transplanted kidney is commonly associated with
recurrent pyelonephritis. Treatment options described in the literature include percutaneous nephrostomy,
ureteral reimplantation or native ureteropyelostomy for stenosis. However, native ureteropyelostomy is
also effective in patients with ureteral reflux and recurrent pyelonephrits.
Methods: From 1997 to 2007, 887 patients underwent kidney transplantation in our department. All
patients entered a prospective database. Ureteral complications were observed in 51 patients (5.7%),
including necrosis (n=9), stenosis (n=32) or ureteral reflux with recurrent pyelonephritis (n=10). Among
the 51 patients with ureteral complications, 35 were treated by native ureteropyelostomy. Clinical data of
these 35 patients was analysed.
Results: Indication for native ureteropyelostomy was necrosis (n=4), stenosis (n=21) and reflux (n=10).
Reconstruction was successful in all patients with necrosis. In 20 of 21 patients with uretral stenosis
native ureteropyelostomy resulted in a decompression of the pyelon and persistently improved renal function. One patient developped stenosis of the native ureter and was treated by endoureteral laser. In 9 of 10
patients with reflux and pyelonephritis, no further febrile episode was documented. One of these patients
developed adhesions of the ureter requiring open adhesiolysis. Postoperative leakage of the anastomosis
occured in two patients and was treated operatively. Thus, the overall success rate was 30 of 35 patients
(86%). We observed no intra- or postoperative mortality. Mean hospital stay was 11 days.
Conclusion: Native ureteropyelostomy is an effective and safe treatment option for ureteral complications
44
like necrosis, stenosis and reflux disease after kidney transplantation. In case of vesicoureteral reflux, the
native antireflux mechanism is reestablished.
23.2
Outcome of kidney grafts with multiple arteries and arterial reconstruction
U. Herden, C.A. Seiler, D. Candinas, S.W. Schmid (Bern)
Objective: Kidney transplantation is the treatment of choice for patients with end stage renal disease.
Increasing numbers of recipients demand an expansion of the donor pool. The aim of our study is to
analyse the outcome of grafts with multiple arteries.
Methods: We prospectively collected and retrospectively analysed all patients undergoing kidney transplantation from 1997 to 2006. Patients were divided into three groups: group I: one artery (n=312), group
II: multiple arteries and one arterial anastomosis to the recipient (n=85), group III: multiple arteries and
multiple anastomosis (n=9). All groups were analysed with regard to graft and patient survival, creatinine
level 1 and 5 years after transplantation, cold and warm ischemic time, operation time and postoperative
complications like artery stenosis, bleeding, acute tubular necrosis or acute rejection.
Results: There were no significant differences between the three groups in graft and patient survival analysed by Kaplan Meier survival curves/log rank test. We found comparable creatinine levels 1 and 5 years
after transplantation (p= 0.86 respective p= 0.31). There was a significant longer operation time in group
3 (mean 180min) compared with group 1 (mean 145min, p<0.05) and a trend to a longer operation time
compared with group 2 (mean 149min, p= 0.06). Warm ischemic time did not differ significantly (mean
group 1: 31min, group 2: 34min, group 3: 38min). Postoperative complications rates for renal artery stenosis, bleeding, acute tubular necrosis and acute rejection were comparable in all three groups.
Conclusion: Our data suggest that kidney grafts with multiple arteries just as multiples anastomosis can
be used safely with comparable outcomes and complication rates.
23.3
Results of in-situ adult-child split liver transplantation in a swiss program.
P.E. Majno, B. Wildhaber, Ph. Morel, T. Berney, L.H. Bühler, M. Bednarkiewicz, O. Huber, C. Chardot, G.
Mentha (Genève)
Objective: To share the results of in-situ split liver transplantation in a mixed adult and pediatric program
while this procedure is to some extent controversial in the opinion of adult transplant centers.
Methods: Since November 1999, 26 in-situ splits for 7 adult and 19 pediatric recipients have been performed in our center. Review of results was performed on the basis of a prospective database.
Results: Pediatric patients were between 6 months and 15 years old (median 1.6 years), adult recipients
were between 33 and 66 years old (median 50 years). After a median follow-up of 3 years (range 6
months to 8 years), overall patient survival was 89% for pediatric patients (one death from graft-versushost disease associated to recipient’s bone marrow aplasia and fulminant hepatic failure, and one late
death from massive pulmonary embolism in a patient with Budd-Chiari syndrome), and 86% for adult
patients (one late death from neurodegenerative disease). Complications in children included primary
non-function (1), requiring retransplantation, hepatic artery thrombosis (1), and biliary problems (7,
36%), none causing graft loss. In adult patients there were no cases of primary non function nor vascular
complications. Biliary complications occurred in two patients and were solved by surgical revision of the
anastomosis.
Conclusion: In the current era of organ shortage, in-situ split liver transplantation appears justified despite
the increased complexity and work burden inherent to the procedure, as it generates grafts of superior
quality. For adults in particular, patient and graft survival figures are excellent and should encourage promoting of the technique in other centers.
23.4
Abdominal drains in liver transplantation: useful tool or useless dogma?
O. de Rougemont, P. Dutkowski, R. Vonlanthen, M. Weber, P.-A. Clavien (Zürich)
Objective: To determine the value of prophylactic drainage in cadaveric orthotopic liver transplantation
(OLT). Based on the growing evidence from randomized trials that routine prophylactic drainage is unnecessary in liver surgery or even harmful in chronic liver disease, we challenged the concept of prophylactic
drainage in OLT.
Methods: Since September 2006, we omitted drains in each patient who underwent OLT regardless of
the procedure. Thirty cadaveric OLTs were performed during a 12-month period. These patients were
matched 1:2 with 60 patients who had prophylactic drainage after OLT according to donor/recipient
age, recipient gender, recipient body mass index (BMI), and MELD score. Matching was performed by
a blinded observer unaware of the clinical outcome after OLT. Endpoints were postoperative morbidity,
in hospital mortality, ICU and hospital stay. Complications were graded according to a therapy-oriented
classification (grade I-V).
Results: Both groups (no drainage n=30, drainage n=60) were comparable in terms of median donor
age (47.5 vs. 52.0 years), recipient age (50.8 vs. 50.9 years), MELD score (24 vs. 24), and BMI (25.9
vs. 26 kg/m2). Due to donor shortage, more marginal grafts were used in the no drainage group: 53
%(16/30) vs. 30%(18/60)(p=0.039). Grade 1-2 (wound infection, rejection) complications occurred
in 73%(22/30) vs. 43%(26/60)(ns), grade 3a (endoscopic/radiological intervention) in 20%(6/30)
vs. 15%(9/60)(ns), grade 3b (surgical intervention) in 23%(7/30) vs. 17%(10/60)(ns), grade 4a (ICU
therapy, intermittent hemodialysis) in 40%(12/30) vs. 22%(13/60)(ns), grade 4b (multiorgan failure)
in 17%(5/30) vs. 12%(7/60)(ns), grade 5 (death) in 7%(2/30) vs. 7%(4/60)(ns). ICU stay was not
significantly different.
Conclusion: This is the first matched case study that challenges the dogma of prophylactic drainage after
OLT. A “no drain” strategy provided no disadvantages despite increased use of extended criteria donors in
the no drainage group. Prophylactic drainage appears unnecessary on a routine basis after OLT.
23.5
Intraoperative ureteric stenting in kidney transplantation – results of a new technique
U. Herden, S.W. Schmid, C.A. Seiler, D. Candinas (Bern)
Objective: Major urological complications (MUCs) like ureteric leak or stenosis are a common problem
after kidney transplantation with an incidence of up to 17.3%. A recent Cochrane review exhibited a
significant reduction in MUCs by routine intraoperative stenting of the vesicoureteric anastomosis. In
most cases a double J stent is inserted, commonly removed after 3-6 weeks. On the other hand ureteric
stenting increases the risk of urinary tract infections and includes the disadvantage of invasive removal.
We present a new technique of ureteric stenting with a percutaneous catheter combining the advantage
of reduced MUCs with minimized stent related complications.
Methods: Prospective analysis of 70 patients undergoing kidney transplantation between 9/2005 – 12
/2006. In all cases a new technique of intraoperative ureteric stenting by a so called “Pflaumer-catheter”
was applied. This catheter is placed suprapubical through the abdominal wall into the urinary bladder,
through the vesico-ureteric anastomosis up to the renal pelvis of the graft. The catheter is routinely removed on postoperative day 5-6 by easy pulling like a standard suprapubic catheter. Antibiotic prophylaxis
was used in every patient during stenting.
Results: No ureteric leaks or stenosis in all 70 patients was observed after a follow-up of median 12
months (range 4-19 months). Only 1 patient (1/70 = 0.7%) suffered from a vesico-ureteric reflux (2
month post-transplantation) and needed Re-UCNS. No patient developed pyelonephritis or transplant loss
due to urinary tract infection. No other specific stent-related complications like irritative symptoms, migration or rupture of the catheter occurred.
Conclusion: Intraoperative stenting with a Pflaumer-catheter proved to be a safe technique preventing
MUCs in our patients. Benefits of our technique are the unproblematic catheter removal and the minimal
risk of urinary tract infections because of the short length of stent placement. In contrast to other types of
stenting, major advantages are the selective measurement of urinary output and the available chemical
analysis of the graft urine for the better evaluation of the transplant function and early identification of
disease recurrence, e.g. Ig A nephropathy.
23.6
Results of living donor liver transplantation in a swiss program
G. Mentha, P.E. Majno, B. Wildhaber, T. Berney, L.H. Bühler, M. Bednarkiewicz, C. Chardot, Ph. Morel (Genève)
Objective: To share the results of living donor liver transplantation in a mixed adult and pediatric program,
while this procedure is to some extent controversial in the opinion of Swiss Health System decision-makers.
Methods: Database review of 17 adult-to-adult (A-) LDLT and 6 pediatric (P-)LDLT (left lobe: segments
2-3) performed in our center siince the beginning of the program in April 1999.
Results: For A-LDLT, the 17 donors were between 20 and 63 years old (median 37 years), 11 women and
6 men. All had been discharged home after 2 weeks, with normal liver function. Major complications were
a bilioma drained under CT, a pneumonia, an occipital patch of alopecia that had to be excised under
local anesthesia, and a biliary fistula that resolved spontaneously. For P-LDLT, all donors were partents
(5 women and 1 man). Donors were discharged after 6 to 10 days without major complications. The
17 adult recipients were between de 29 and 58 years old (median 53 years), there were 6 women and
11 men. Median graft to recipient weight ratio was 1% with 2 cases below 0.8 %. The middle hepatic
vein was harvested with the graft and in 3 cases and a venoplasty with the hepatic venous branches
to segment 5 and 8 was done in 3 cases. Vascular complications occurred in two patients, both having
required interposition grafts, portal (1)and arterial (1), and biliary complications in 6 patients, (2 leaks
and 4 strictures), none leading to graft loss. Three patients died: one patient at two months from MOF, one
patient at 11 months because of tumor recurrence (sarcomatous hepatocellular carcinoma), and one
patient at 4 years because of Hepatitis C virus recurrence. All P-LDLT recipients are alive with a functioning
graft (follow up 6-44 months). After a median follow-up of 48 months, (range 1 to 104 months), actuarial
patient and graft survival rates were 85% at 1 year, 78% at 3 years and 72% at 5 years.
Conclusion: In the current era of graft shortage LDLT appears justified by the results that are similar to
liver transplantation from deceased donors. The procedure seems particularly appropriate for patients
without foreseeable surgical problems, and quality of life deterioration that is underweighted by the current allocation system.
Visceral Surgery
25
25.1
Is a subclinical peri-operative adrenal insufficiency associated with an increased rate of postoperative
complications in patients undergoing visceral surgery?
P. Studer1, L. Brander1, T. Haltmeier1, S. Jakob1, J. Takala1, C. Henzen2, D. Candinas1, D. Inderbitzin1 (1Bern,
2
Luzern)
Objective: Subclinical adrenal insufficiency in surgical patients is described in up to 33% of patients and
might be responsible for an increased rate of postoperative complications and potentially delayed recovery. It therefore seems attractive to correlate adrenal function and the postoperative clinical course (i.e. the
rate of complications) in randomly selected patients undergoing elective visceral surgery.
Methods: A total of 108 patients were included in the study. Mini (1_g)-ACTH test was performed at four
time points (before, during planned abdominal surgery, first day postoperatively, and at the last day of
hospitalisation). Total cortisol and cortisol binding globulin (CBG) were measured before and 30 min after
ACTH administration, and the free-cortisol-index was calculated (FCI=total cortisol/CBG). Postoperative
complications were identified according to approved international standards. Mini ACTH test responses
were grouped in four equally numbered quartiles (each n=27 patients), with the low responders in quartile one. The incidence of postoperative complications was then compared with the mini ACTH response
rates. To rule out potential systematic sampling errors the individual morbidity was predicted according
to the E-PASS system.
Results: Postoperative complications were seen in 10 patients (37%) of the low response quartile one, in
4 patients (15%) of quartile two, in 6 patients of quartile three (22%), and in 8 patients (29%) of the high
response quartile four. All patient groups showed a homogenous and comparable distribution of E-PASS
scores and a complete lack of correlation with the ACTH response.
Conclusion: Low cortisol levels and a decreased response to mini ACTH stimulation are common in routine abdominal surgery patients. In this series of patients, adrenal dysfunction had no clinically detectable
effect on the postoperative course.
25.2
Fast track surgery does not reduce morbidity in patients at nutritional risk
M. Hübner1, S. Müller1, P.-A. Clavien2, N. Demartines1 (1Lausanne, 2Zürich)
Objective: Patients with a Nutritional Risk Score (NRS) ≥ 3 have a higher risk for complications. Fast track
programs in colonic surgery reduce complication rate and hospital stay. The aim of this analysis was to
assess if patients with NRS ≥ 3 benefit of a fast track program.
Methods: In a recent randomized trial we compared complications after colonic surgery with either a fast
track program (FT) or standard care (SC). A subgroup analysis was performed in 67/156 patients of the
initial study for which a prospective NRS was available.
Results: SC group (n=31) and FT group (n=36) did not differ regarding patient characteristics or prevalence of NRS ≥ 3 (SC: 8/31, FT: 7/36, P=0.569). Patients with SC had more complications (14/31 vs
8/36, P=0.044) and a longer median hospital stay (9 vs 5 days, P<0.0001) compared with FT. No major
complications occurred in patients with an NRS < 3 in either group. However, patients with a NRS ≥ 3 had
high postoperative complications regardless of SC and FT (6/8 and 5/7, respectively).
Conclusion: A fast track program in colonic surgery does not reduce morbidity in patients with a NRS ≥
3. Nutritional screening is mandatory in order to administer preoperative supplementation in patients at
nutritional risk.
25.3
D-dimer level after surgery: when does it normalize?
D. Dindo, S. Breitenstein, D. Hahnloser, B. Seifert, S. Yakarisik, L.M. Asmis, P.-A. Clavien (Zürich)
Objective: Plasma D-dimer levels might be elevated after surgery. Uncertainty exists about the use of Ddimer as postoperative diagnostic means for detection of thromboembolic events since its natural course
after surgery is unknown.
Methods: Plasma D-dimer levels were determined preoperatively and at various time points (day 1, 3, 5,
7, 10, 14, and weekly thereafter until levels returned to normal) in 144 consecutive patients after visceral
surgery. Surgical operations were stratified based on the degree of severity (type I: not opening abdominal
cavity; type II: intraabdominal operation not being type III; type III: retroperitoneal (pancreas, esophagus,
rectum) and liver surgery). Clinical factors influencing the peak of D-dimer levels were analyzed using
multivariate regression. D-dimer degradation was studied and a degradation formula was calculated.
For validation, the degradation formula was applied on 43 patients comparing predicted with measured
values.
Results: D-dimer levels increased postoperatively peaking on day 5-7. Peak D-dimer levels (median with
inter-quartile range) reached 0.3_g/ml (0.2-0.6) in type I, 1.5_g/ml (1-3.2) in type II, and 4.0_g/ml (2.35.2) in type III surgery. Peak D-dimer levels were independently influenced by the invasiveness of surgery
(p<0.0001), operation time (p=0.003), amount of blood loss (p=0.009) and by preoperative D-dimer levels (greater to normal; p<0.0001). Degradation of D-dimer was almost exponential after having reached
the peak with a clearance of 6% per day (r2= 0.72 on a log scale). After type II surgery, D-Dimer returned
to normal values after 25 days (+14) and following type III surgery after 38 days (+11).
Conclusion: D-dimer levels increase postoperatively depending on the type of surgery and the degradation of D-dimer is almost exponential. Based on these findings, normalization of D-dimer levels after surgery
might be predicted.
25.4
Quality assessment in surgery: are you on the right track?
D. Dindo, D. Hahnloser, P.-A. Clavien (Zürich)
Objective: Quality assessment in surgery is increasingly becoming important for patients and health care
providers. In our department, risk factors and complications are prospectively assessed by residents
using a simple, validated five-scale complication classification system. However, validity of such data
collection is unknown.
Methods: Over a 6 months period, recording of complications in 752 consecutive patients was reviewed
by an external clinical nurse. After 3 months, the residents were informed about their performance, and
subjected to a teaching course. Then, outcome assessment was continued and compared between the
two periods. A survey inquired the methods of surgical quality assessment in 76 international centers.
Results: Identified complications were graded correctly in 98%. However, residents failed to report most
complications with 80% (164/206) and 79% (275/347; P=0.3) being missed during the first and second period, respectively. Reliability of recording grade I complications (94% and 89% missed, P=0.1)
and Grade II (54% and 59%, P=0.4) did not improve. Completeness of reporting Grade III complications
(71% and 47% missed, P=0.047), Grade IV (1/1 and 1/4, P=0.6) and grade V (1/1 and 0/3, P=0.25)
improved, but still remained poor. Outcome is prospectively collected in 89% of surveyed international
45
centers and felt to be sufficient in 75%. However, resident record the data in 40% and risk factors are only
assessed in two thirds of the centers hampering the interpretation of reported outcome.
Conclusion: Recording of complications by residents is dramatically deficient, and therefore cannot be
used for quality assessment. Documentation of surgical outcome by dedicated personnel is necessary
for reliable quality control.
25.5
A follicular carcinoma of the thyroid gland smaller than 11mm – does it really exist?
W. Kolb1, C. Kull2, E. Bareck3, C. Dotzenrath4, B. Niederle3, T. Clerici1 (1St. Gallen, 2Liestal, 3Wien/AT, 4Wuppertal/DE)
Objective: There is considerable controversy among clinicians and pathologists on the subject whether
follicular thyroid carcinomas (FTC) smaller than 11 mm in size (pT1, TNM-classification 5th edition) do
exist and on what the clinical significance of this tumour entity is.
Methods: The members of the German speaking association of Endocrine surgeons (CAEK) where asked
to review their patients operated on for a follicular cancer for cases with a tumour size smaller 11 mm. 26
institutions contributed the clinical and histopathological data of a total of 90 patients to this study. The
aim of the study was to assess the relative frequency of this tumour entity, its characteristics and prognosis and to analyse the treatment-modalities that had been applied. The histological material of 46 patients
underwent a re-evaluation by three specialized pathologists.
Results: In 35 of the 46 cases undergoing a histopathological review the available material was adequate
enough to allow a reassessment of the primary diagnosis of a FTC<11mm. In the majority the inicial
diagnosis had to be revised because of the fact the size was not properly assessed or because of a false
tumour diagnosis (e.g. benign adenoma or the follicular variant of a papillary cancer). The diagnosis of a
FTC<11m was confirmed in only 4 cases (11%). For one closed geographic area (Eastern Switzerland)
all cases of its tumour registry with FTC <11mm could be completely assessed and underwent a complete re-evaluation by a reviewer-pathologist. For this closed geographic region the real incidence rate for
FTC<11mm can be established: it is only 0.12 per million inhabitants per year.
Conclusion: Even if this case collection study has its limitations we can conclude that FTC<11mm are very
rare and that this tumour entity is over-diagnosed. Many patients undergo unnecessary therapies with its
morbidities and costs (completion-thyroidectomy, radioiodine-ablation, thyroxin-replacement). Therefore
a histopathological re-evaluation by an experienced pathologist must be strongly recommended before
embarking in further treatments when the diagnosis of an FTC<11mm is made.
25.6
Decision analysis show frozen section in thyroid surgery as dominant strategy despite moderate accuracy
U. Herden, S.W. Schmid, S. Vorburger, D. Candinas, C.A. Seiler (Bern)
Objective: The routine use of intraoperative frozen section analysis (FS) in surgery for thyroid nodule is
controversial. A positive FS allows an adaptation of the intraoperative strategy avoiding the risks and costs
of re-operations. However, its low sensitivity to detect well-differentiated cancer led many surgeons to rely
solely on the definitive pathological workup preventing additional costs of FS. The aim of this study was to
determine the accuracy of FS in our institution and to perform a decision analysis of our results and data
reported in the literature.
Methods: A prospective database of all patients undergoing thyroid gland surgery between 01/2002 and
12/2006 was analysed. FS reports were compared to definitive histological results. Impact of FS on the
surgical strategy and costs according to DRG was evaluated. A decision analysis for cost/patient based
on incidence of malignancy and accuracy of FS was performed. Literature assessing FS in thyroid surgery
within the last decade was considered in this analysis.
Results: 624 patients underwent thyroid surgery and FS for single or multiple thyroid nodules. Definitive
histology showed malignancy in 109 patients (17.5%), with 102 (94%) well-differentiated thyroid cancer
(papillary n=82; follicular n=20). In case of malignancy reported in FS operation was normally changed
to total thyroidectomy with bilateral cervico-central and ipsilateral cervico-lateral lymphadenectomy. If FS
was not conclusive or negative re-operation depended on definitive histology. Frozen section analysis was
correct in 553/624 (88.6%) patients, unclear in 22/624 (3.5%) and false negative in 49/624 (7.9%).
Hence, sensitivity was 36.7% and specificity 100% (no false positives). Frozen section altered surgical
strategy and avoided re-operation in 34 of 109 patients with thyroid cancer (31.2%). DRG costs for thyroidectomy (code 290) are 6822 CHF, costs for FS (2x slides) are 186 CHF. Decision analysis showed
that FS was more effective if incidence of malignancy and accuracy of FS was increased. Already at low
cancer incidence of 10% and an accuracy of 35% performing a FS became the dominating strategy to
save costs. With the reported incidence and accuracy of FS, all but one study would have been more costeffective with FS performed, also for studies opposing the use of FS due to costs or diagnostic inaccuracy.
Costs of prolonged hospital stay, loss of working days, quality of life and increased risk of nerve lesion in
re-operation were not included in this decision analysis. These factors would additionally increase the
dominance of performing a FS. For our patients FS saved direct costs of about 150 CHF/patient.
Conclusion: Assuming a low rate of false-positives, FS reduces direct costs, enhances patient’s comfort
and avoids risks of re-operations. This was found in virtually all studies on FS reported within the last decade. Routine use of FS is by far the dominating cost-effective strategy and should be advocated.
Research
26
26.1
Erythropoietin improves survival of critically perfused musculocutaneous tissue by upregulation of nitric
oxide synthase and vascular endothelial growth factor
F. Rezaeian1, R. Wettstein1, K. Bäumker1, M.D. Menger2, B. Pittet-Cuénod1, Y. Harder1 (1Genève, 2HomburgSaar/DE)
Objective: Erythropoietin (EPO), the main regulator of erythropoiesis, is approved for treatment of certain
types of anaemia. Irrespective of its erythropoietic properties, EPO has recently been attributed tissueprotective effects in severe ischaemia of brain, heart and liver tissue. Persistent ischaemia in flap tissue
leads to wound breakdown and tissue necrosis. The aim of this study was therefore to elaborate the effect
of EPO in a model of ischaemic musculocutaneous flap tissue with an emphasis on underlying microcirculatory and cellular mechanisms.
Methods: A randomly perfused musculocutaneous flap integrated in a dorsal skinfold chamber of
C57BL/6-mice was used as a model for persistent ischaemia. EPO (500 IU/kg bodyweight; n=8) was
administered intraperitoneally 30 minutes before as well as 30 minutes and 24 hours after flap elevation in the study group (EPO). A second group of animals (n=8) receiving saline 0.9% served as control
(CON). Arteriolar diameter, functional capillary density (FCD), angiogenesis (mean vessel density; MVD)
and flap necrosis were assessed with repetitive epi-fluorescence microscopy over a 10-day period. Ischaemia-induced inflammatory response was determined by leukocyte-endothelial cell interaction and
apoptotic cell death. Western blot analyses and immunohistochemistry were performed to quantify the
expression of inducible nitric oxide synthase (iNOS), endothelial NO-synthase (eNOS) and vascular endothelial growth factor (VEGF). Haematocrit and haemoglobin concentration were measured in separate
sets of animals (n=8 each).
Results: Increased expression of iNOS (6-fold vs CON) and eNOS (2-fold) in EPO-treated mice correlated with significant arteriolar dilation (CON: day1 after flap elevation: 49±3mm, day10: 52±5mm; EPO:
day1: 65±3mm, day10: 77±5mm; p<0.05 vs CON) and maintained FCD at day 10 (CON: 60±2cm/cm2;
EPO: 119±13cm/cm2; p<0.05). Also, EPO induced an early VEGF-upregulation (3-fold) resulting in newly
formed capillaries (MVD at day 10: CON: 0±0cm/cm2; EPO: 33±3cm/cm2; p<0.05), and significantly
decreased leukocyte adherence and apoptotic cell death. Consequently, EPO pre-treatment resulted in a
significant reduction of flap necrosis (CON: 48±2%; EPO: 20±3%; p<0.05). Both haematocrit and haemoglobin were not influenced by the dosage of EPO used .
Conclusion: In absence of a haematocrit-relevant effect EPO-administration led to significantly improved
tissue survival by a NO-dependent increase in microcirculatory perfusion, an attenuation of the inflammatory response to ischaemia, and a VEGF-mediated angiogenic response with the formation of functional
neocapillaries. Since these changes are initiated before flap surgery, pre-treatment with EPO seems a
promising non-invasive method to reduce ischaemia-related complications in elective surgery at risk of
wound breakdown and tissue necrosis.
26.2
Influence of maturation stage of engineered cartilage on the outcome of osteochondral repair in a goat
model
S. Miot1, W. Brehm2, S. Dickinson3, A. Hollander3, E. Tognana4, P. Mainil-Varlet2, M. Heberer1, I. Martin1
(1Basel, 2Bern, 3Bristol/UK, 4Abano Terme/IT)
Objective: We investigated how the stage of development of engineered cartilaginous tissues influences
the repair outcome of large osteochondral defects in a goat model.
Methods: Engineered cartilage was generated from autologous articular chondrocytes cultured in Hyaff-11 meshes (FAB) for 2 days, 2 weeks or 6 weeks and implanted on top of hydroxyapatite/Hyaff-11
sponges into osteochondral defects. Experimental settings included defects that were untreated or treated with cell-free scaffolds. The repair was assessed histologically and biochemically 8 months post
implantation. Sections were scored according to a Modified O’Driscoll classification where grades for
each variable were summed to yield a mean O’Driscoll score (minimal score: 0 for normal osteochondral
tissue; maximal score: 31). For statistical analysis, means were compared using either Student’s t-test or
Mann Whitney test depending on the normality of the populations tested by Shapiro-Wilk tests, with p<
0.05 as the criteria for statistical significance.
Results: Glycosaminoglycan (GAG) and type II collagen contents in engineered tissues progressively increased with culture time. Implantation of the biomaterial into the subchondral compartment induced
an extensive remodelling of the surrounding bone. No significant differences in GAG, type-I and -II collagen content between experimental groups were observed in the repair tissue overlying the subchondral
part due to large experimental variability. Modified O’Driscoll scores indicated poor cartilage repair for
untreated and cell-free treated groups (29.7±1.6, 24.3±5.8). Instead, in groups using cells, a significant
improvement in the cartilage repair process was noticed, with better scores observed for 2 days and 2
weeks (17.3±8.4, 16.3±5.8) than for 6 weeks (22.3±6.4) preculture time. In particular, the implantation
of engineered cartilage grafts was associated with an improved surface smoothness and more regular
filling of the defect, as well as with higher cartilaginous quality of the repair tissue.
Conclusion: In this animal model, as compared to implantation of a cell-free Hyaff-11 scaffold, the preculture of an engineered cartilage graft for up to 2 weeks improved the outcome of cartilage repair, although
more extensive maturation of the constructs did not bring additional benefit.
26.3
Monitoring of cellular immune responses in whole blood: a simple, sensitive and accurate PCR-based
method
E. Schultz-Thater, P. Zajac, D. Margelli, G. Spagnoli, D.M. Frey (Basel)
Objective: Monitoring of cellular immune responses against tumor associated antigens (TAA) or micro
46
organism derived antigens may require advanced cellular immunology skills and the application of time
consuming protocols. Real-time PCR (qRT-PCR) was applied as a simple and sensitive technique in order
to characterize antigen specific cellular immune responsiveness in small samples of whole blood from
patients or healthy donors following vaccinations or natural sensitization to specific antigens.
Methods: Defined antigens, in the form of peptides or commercial vaccine preparations at concentrations
ranging between 1 and 5 µg/ml are added to 0.3 ml of heparinized peripheral blood. Samples are then
centrifuged to bring cells in contact and cultured o/n at 37°. Four volumes of RNAlater (Ambion, Houston
TX) are then added to provide RNA stabilization. Specimens can now be stored for over a week at 4°C or
sent to another laboratory. Following RNA extraction and reverse transcription, cDNA is then amplified in
the presence of primers and probes specific for defined cytokine genes, including those encoding IL-2,
IFN-g, IL-6, IL-10, TNF-a or MIP-1b. Antigen driven cytokine gene expression is evaluated in relationship to
the expression of b-actin house-keeping gene.
Results: Cytokine gene expression and specific antibody titers were initially studied in donors (n=32) vaccinated against hepatitis B virus. Significant correlations between antigen stimulated expression of IL-2,
MIP-1b, TNF-a and IFN-g genes and specific antibody titers (p=0.0003, p=0.001, p=0.003 and p=0.015,
respectively) were detected. In our hands, this technique demonstrates similar sensitivity than ELISPOT or
intracellular staining with cytokine specific mAbs. In spiking experiments performed with different amount
of specific cytotoxic T lymphocyte (CTL) for gp100 melanoma TAA, qRT-PCR was able to detect specific
responses of 100 CTL added to 300ul of whole blood. Similarly, we were able to demonstrate EBV BMLF
1 or CMV pp65 specific responses in peripheral blood from seropositive healthy HLA-A0201+ donors
stimulated with peptides.
Conclusion: In this study, real-time RT-PCR demonstrates a high sensitivity to detect antigen specific functional activities of lymphocytes in whole blood, suitable for the monitoring of immune responses against
viral or tumor associated antigens.
26.4
Uremia-induced changes in morphology and stability of rat femurs
A.E. Pasch1, N. Renner1, A. Pasch2, S. Farese2 (1Aarau, 2Bern)
Objective: Renal osteodystrophy is a common complication of end stage renal disease and is associated
with increased fracture rates. Reduced bone mineral content and increased bone fragility may lead to
surgical treatment challenges mainly as a consequence of impaired anchoring of osteosynthetic devices.
The aim of this study was to evaluate whether adenine-induced uremia in rats might lead to comparable
renal osteodystrophy bone changes as in humans and therefore might serve as a suitabel model for
future studies on the surgical treatment of renal osteodystrophic bone.
Methods: Interstitial nephritis and uremia was induced in six week old male Wistar rats (n=14) by a standard rat chow containing 0.75% adenine for four weeks. Non-uremic rats (n=5) served as controls. All
rats were sacrificed at age 16 weeks and femurs were removed. Bone structure was evaluated morphologically by micro-CT scans. Bone stability was evaluated functionally by assessing bone distensibility
(N/mm) and load to fracture (N) by use of a uni-axial electro-mechanical testing machine with 4-point
binding compression mode.
Results: Adenine-fed rats had higher serum creatinine levels (224 ± 73 vs. 44 ± 11 µ mol/L), parathyroid
hormone levels (563 ± 121 vs. 46 ± 19 pg/mL) and lower hemoglobin levels (108 ± 17 vs. 149 ± 14
g/L) when compared to their non-uremic littermates (p < 0.001 for all comparisons). Femurs from uremic
animals were shorter than bones obtained from non-uremic rats. Micro-CT scans and histology revealed
solid and intact cortical bone structures in non-uremic rats, whereas uremic bone exhibited porous and
pot-holed cortical structures. Bone distensibility was markedly enhanced (344 ± 41 vs. 124 ± 31 N/mm, p
< 0.0001) and load to fracture was reduced (106 ± 26 vs. 209 ± 27 N, p < 0.0001) in uremic bones.
Conclusion: Bones obtained from adenine-fed uremic rats exhibit features also encountered in human
chronic kidney disease and might therefore serve as a valuable model for fracture and fracture treatment
studies of renal osteodystrophy.
26.5
Towards an intraoperative engineering of osteogenic and vasculogenic grafts from the stromal vascular
fraction of human adipose tissue
A. Müller, A. Scherberich, D. Schäfer, M. Jakob, M. Heberer, I. Martin (Basel)
Objective: Mesenchymal and endothelial lineage cells isolated from the stromal vascular fraction (SVF)
of adipose tissue have recently proven osteogenic and vasculogenic capacity in vivo when seeded and
expanded inside 3D hydroxyapatite scaffolds in a perfusion system for five days. However, compliance
and practicability in the clinical field might be hampered by the requirement of a costly GMP facility to engineer the bone substitutes and the need for two surgical procedures, since implantation would take place
only a few days after cell harvest. In this study we aimed at evaluating the feasibility of an intraoperative
approach to engineer cell-based bone grafts, with tissue harvest, cell isolation, cell seeding in the scaffold
and subsequent implantation within a few hours.
Methods: SVF cells were isolated from lipoaspirates and excised fat samples of 7 healthy donors (37-84
years old) by enzymatic digestion. Freshly isolated SVF cells were analysed by cytofluorimetry for the
expression of surface antigens of the endothelial and mesenchymal lineage cells. The frequency of clonogenic mesenchymal cells was determined in colony forming unit assays. SVF cells (2.5x105 to 6x106)
were then embedded in a fibrin matrix and wrapped around tricalciumphosphate (ChronOs, Synthes)
and hydroxyapatite (Engipore®, Finceramica) cylinders. Cell-fibrin-scaffold constructs were then immediately implanted in the subcutaneous tissue of nude mice for eight weeks. Upon explantation, constructs
were decalcified, embedded in paraffin and sectioned. The presence of human derived bone tissue was
assessed by staining with H&E, Masson trichrome and antibodies against human bone sialoprotein
(BSP), as well as in situ hybridisation for the typically human ALU sequences. Antibodies against human
CD34 were used to assess the presence of human endothelial cells.
Results: The SVF yielded 2x105±1.5x105 nucleated cells, of which 8%±6.5% were clonogenic. Thus, the
cell-scaffold constructs were initially loaded with 3x104 to 1.1x106 clonogenic cells. 27± 4% of freshly
isolated SVF cells expressed mesenchymal (CD105 and CD90) and 43±34% endothelial (CD31 and
CD34) markers. After eight weeks of ectopic implantation, the endothelial fraction of SVF cells was capable to support the formation of blood vessels within the construct with functional connection to the host. The
mesenchymal cell fraction formed a dense matrix positive for BSP with similarity to an osteoid tissue in
areas initially loaded with human clonogenic cells. However, frank bone formation was never observed.
Conclusion: Here we provide a proof-of-principle that intraoperative engineering of autologous cell-based
bone graft substitutes could be achieved by wrapping adipose tissue stromal cells embedded in a fibrin
matrix around ceramic-based scaffolds. Further studies are necessary to determine whether the engineered constructs, implanted in a relevant orthotopic model, would be able to induce de novo formation
of bone tissue.
26.6
Improvement of vascularization of PLGA scaffolds by inosculation of in situ preformed functional blood
vessels with the host microvasculature
M.W. Laschke1, M. Rücker2, G. Jensen1, C. Carvalho3, R. Mülhaupt3, N. Gellrich2, M.D. Menger1
(1Homburg-Saar/DE, 2Hannover/DE, 3Freiburg/DE)
Objective: In tissue engineering, a rapid and sufficient vascularization is crucial for the long-term survival and function of implanted tissue constructs. Accordingly, several approaches are currently under
investigation to promote a rapid ingrowth of new blood vessels into tissue constructs such as coating
of scaffolds with pro-angiogenic growth factors. However, all of these approaches do yet not result in a
sufficient blood supply during the first days after scaffold implantation. Therefore, the aim of the present
in vivo study was to analyze, whether the blood supply to implanted scaffolds could be accelerated by
inosculation of an in situ preformed microvascular network with the host microvasculature.
Methods: Porous poly-lactic-glycolic acid (PLGA) scaffolds (n=16) were implanted into the flank of balb/c
or GFP-transgenic mice for 20 days to create in situ a new microvascular network within these scaffolds.
Then, the prevascularized scaffolds were carefully excised and transferred into the dorsal skinfold chamber of isogeneic recipient mice. Empty PLGA scaffolds without preformed blood vessels served as controls (n=10). Subsequently, we analyzed vascularization, incorporation and cell survival of the implants
over 14 days by means of intravital fluorescence microscopy, histology and immunohistochemistry.
Results: We found that vascularization of in situ prevascularized scaffolds was significantly accelerated
and improved when compared to controls, as indicated by an increased functional capillary density in
the border (307±13cm/cm_ vs. 157±21cm/cm_, p<0.05) and center (227±21cm/cm_ vs. 37±10cm/
cm_, p<0.05) of the scaffolds at day 14 after implantation. This was due to the ability of preformed microvessels to be reperfused by forming interconnections to the host microvasculature. Correspondingly,
blood perfusion of prevascularized scaffolds (day 14: 137±23pl/s) was markedly improved when compared to controls (day 14: 7±2pl/s). In addition, the preformed microvessels represented also the origin of
newly developing blood vessels, growing into the granulation tissue surrounding the scaffolds. Apoptotic
cell death within the implants was found only during the first 3 to 6 days after scaffold implantation during
lack of blood perfusion, but not during the further 14-day observation period.
Conclusion: The present study demonstrates that inosculation of in situ preformed functional microvascular networks with the host microvasculature represents a promising approach to improve vascularization
and blood perfusion of tissue engineering constructs.
31
Video
31.1
Extended abdomino-perineal resection with sacral resection for locally recurrent rectal cancer
C. Buchli1, M. Attinger1, T. Holm2, P. Villiger1 (1Chur, 2Stockholm/SE)
Objective: Despite improvements in local control and survival in patients with rectal cancer, mainly due
to the implementation of Total Mesorectal Excision (TME) and the use of neoadjuvant or adjuvant radiotherapy and chemotherapy, a considerable number of patients will still develop a local recurrence. These
patients should be considered for extensive work up, including CT scan or PET-CT, MRI and colonoscopy;
to exclude distant metastases, delineate the local tumour and exclude synchronous colon cancer. About
50% have no metastases and the recurrent tumour is confined to the pelvis. All such patients should be
discussed at a multidisciplinary team meeting, aiming at a curative resection of their locally recurrent
rectal cancer. Those who have not previously had radiotherapy should be offered full course preoperative
radio-chemotherapy. In many cases the recurrent tumour has a posterior location, close to or invading
the pelvic floor or sacrum. The aim of this video is to describe the preferred surgical technique in such
patients.
Methods: The operation is performed in two stages. The abdominal part should define and isolate the
upper, anterior and lateral borders of the tumour, including en bloc resection of any adjacent organ or
structure. If a previous anterior resection has been performed, the bowel is divided well above the promontory and the neorectum is mobilised anteriorly to just below the vesicles and laterally down to the
insertion of the levator muscles to the lateral pelvic sidewalls. Posteriorly, the dissection should stop above
the level where MRI has shown a close proximity or an infiltration. A guide-wire is inserted through the
sacrum to indicate the appropriate level of trans-section. A colostomy is constructed and the abdomen is
closed. The patient is placed in the prone jack-knife position. A midline incision is made over the perineum
and sacrum, including the anus. The dissection follows the levator muscles to the pelvic sidewalls and
the sacrum is exposed. Based on the position of the guide-wire at the posterior part of the sacrum, the
bone is divided to enter the pelvis. The levator muscles are divided on both sides towards the prostate or
vagina. The specimen is then brought out and the resection is completed by dissecting it off the prostate or
posterior vaginal wall. Alternatively, if the point of division of the sacrum is difficult to define, the dissection
may follow the prostate up to the vesicles and into the pelvis. The levators and ligaments are then divided
and finally the sacrum is divided.
47
Results: –
Conclusion: R0 resection is a prerequisite for cure in patients with locally recurrent rectal cancer. By the
described extended abdomino-perineal resection with sacral resection, en bloc with the tumour, this may
be achieved.
QoL questionary showed a satisfactory result in 90% of patients.
Conclusion: Laparoscopy is usefull, safe and feasible to resolve a rectal prolapse in adults. It has low
morbidity rate, with attendant benefits of reduced length of hospital stay, postoperative pain, wound complications and a higher index of satisfaction (QoL)
31.2
31.5
Total robotic Roux-en-Y gastric bypass
Ph. Morel, F. Pugin, I. Inan, G. Chassot, M. Hagen (Genève)
Natural Orifice Translumenal Endoscopic Surgery (NOTES) for Roux-en-Y gastric bypass
M. Hagen1, F. Pugin1, O.J. Wagner2, P. Swain3, P. Bucher1, N.C. Buchs1, J.H. Fasel1, Ph. Morel1 (1Genève,
2
Bern, 3London/UK)
Objective: Laparoscopic Roux-en-Y Gastric Bypass (RYGBP) with stapled anastomoses is a standard
procedure in treatment of obesity. Still, the procedure is associated with certain complications (overall: up
to >30%, leakage:>2%, strictures:>4% according to the literature). Robotic suturing of the gastro-enteroanastomoses during RYGBP is performed in a few centers worldwide and might be superior to stapled
anastomoses (Lower anastomotic leakage and stricture rates, faster learning curves, shorter OR times).
However, due to the specific design of the da Vinci® robot, setup for total robotic RYGBP is difficult. Since
we have performed a significant number of robotic-assisted RYGBPs, we now regularly schedule total
robotic RYGBPs.
Methods: We have recorded and edited a total robotic RYGBP. Moderation will be held on site.
Results: The video shows a total robotic RYGBP with robotically sewn, single layer gastro-entero- and
entero-entero-anastomoses with the da Vinci® Surgical System.
Conclusion: The video demonstrates the general feasibility of total robotic RYGBP with the da Vinci® Surgical System for obesity and its potential superiority over conventional laparoscopy. Clinical outcomes and
analysis of procedure are subjects to ongoing research.
31.3
Stapled TransAnal Rectal Resection (STARR) with Contour® TranstarTM in Obstructed Defecation Syndrom (ODS)
F. Hetzer, H. Marlovits, K. Wolff, U. Beutner, J. Lange (St. Gallen)
Objective: The stapled transanal rectal resection (STARR procedure) is an effective treatment for obstructed defecation syndrome (ODS) caused by intussusception and rectocele. Recently a new technique
has been developed using the new Contour® Transtar™ stapler, which was specifically designed to facilitate the STARR procedure. We report our first experience with this new technique.
Methods: Patients still suffering from ODS after completed conservative treatment and rectal redundancy
in MR-defecography were included. Data were prospectively collected in a web-based database and included details of preoperative assessment, surgical intervention and postoperative outcome. Functional
outcome was assessed using Longo’s Obstructed Defaecation Syndrome Score (ODS Score), a Symptom Severity Score (SSS), and the Cleveland Clinic Continence Score.
Results: From January to November 2007, 20 consecutive patients (19 female) were enrolled with a
median age of 64 years (range 20-87). Median operation duration was 43 min (30-200) and hospital
stay was 6 days (2-8). The median specimen weight was 27 g (15-53). In one patient an intraoperative
anastomotic dehiscence occurred. At 6 weeks follow-up, the overall morbidity was 40%consisting only
of minor complications (one patient each with self limiting bleed, persistent pain, perianal thrombosis
requiring incision, minor incontinence together with fecal urgency; five patients with minor incontinence).
Neither sepsis, fistula nor deaths were reported. At 6 weeks follow-up (N=20) the median ODS score and
SSS were significantly lower than pre-operatively (ODS pre-op: 14 (8-18), 6 weeks po: 5 (2-12), P<0.0001,
paired Wilcoxon test. SSS pre-op: 14 (6-21) 6 weeks po: 3 (0-19), P<0.0001). Each patient had lower
scores at the 6 week follow-up than pre-operatively. At the 3 month follow-up (N=19) the median SSS was
further reduced (2 (0-8), P=0.041 compared to 6 weeks po) while the median ODS score did not change
significantly (4 (2-12), P= 0.17). No patient had an increased Continence Score 3 months po. (pre-op: 0
(0-20), 3 months po: 0 (0-5), P=0.012).
Conclusion: Contour® Transtar™ is a safe and effective treatment for ODS with an acceptable morbidity
rate. Comparative studies are needed to fully evaluate its clinical benefit and its preferential use over existing techniques for STARR.
31.4
Laparoscopy surgery for rectal prolapse
X. Delgadillo, F. Cespedes, P. Shoeni (La Chaux-de-Fonds)
Objective: Full-thickness prolapse of the rectum causes perineal discomfort, soiling, spoting, mucosalbleeding, and anal sphincter incontinence. Treatment of rectal prolapse is surgical. Perineal repairs are
well tolerated, but are associated with higher recurrence rate. Abdominal repair fixing the rectum by using
mesh or sutures has lowest recurrence rate. The pourpose of our study is to demonstrate the safety and
feasability of laparoscopy in the management of rectal prolapse in adults. This DVD is also usefull for
trainees in surgery for their basis in surgical anatomy and fundamentals of the technique.
Methods: From october 2007 to january 2008, five consecutive patients (all women), median age 53
years (range: 26 – 74 years), underwent laparoscopic rectopexy to sacrum for rectal prolapse in our
institution. Pre-operative evaluation included proctological examination, endoanal ultrasound and radiology-proctography. Postoperative evaluation added a global quality-of-life questionnary (QoL). Well‘s
procedure was performed in 2 and Ivalon plaque implant in 3 patients. A full laparoscopic procedure was
performed applying the synthetic prosthesis for rectal fixation to the promontory in all women.
Results: No conversion to laparotomy was necessary. Complete reduction of the prolapse was obtained in
all cases. Median operative time was 93 minutes (mean 55-112 min.) Antibiotherapy was administrated
intravenously during 48 hrs (3.6 g/day Amoxicyllin-Clavulanate). No morbidity was reported. In all cases
the anal incontinence and symptoms (soiling, spoting and mucosal-bleeding) were highly diminished. In
four patients a mild constipation was resolved with soft laxatives. Mean hospital stay was 4.3 days (3.55.1). A 100% of patients had a biofeedback training after the operation. The follow up was uneventfull. The
48
Objective: Advantages of a NOTES or NOTES hybrid approach to Roux-en-Y gastric bypass (RYGB) might
include: easier access to the peritoneal cavity, subtantial reduction in number of ports and port related
complications, improved cosmesis and others. NOTES was initially concieved as a procedure for relatively minor intraperitoneal operations. The most common NOTES procedure currently is cholecystectomy
which is of moderate complexity. RYGB is a complex surgical procedure of advanced level. The technical
feasibility of a NOTES-RYGB and limitations of available flexible and rigid instrumentation for such a procedure is unknown.
Methods: NOTES hybrid RYGB was performed until now in 6 human cadavers (frozen or preserved) using
a combination of flexible and rigid instruments. Procedures were recorded and edtited. This video shows
the procedure of one cadaver. Moderating will be held on sight.
Results: This video shows pouch creation achieved by needle knife dissection of a retrogastric window
using a flexible gastroscope introduced transvaginally. Articulated linear staplers are placed through a
transumbilical port to transect the stomach. Measurements of the bilary and alimenary limbs are accomplished with flexible and rigid graspers in this video. A 21 mm anvil is introduced through a needle-knife
incision into the small intestine and connected to the flexible shaft of a flexible transesophageal stapler
to form a gastrojejunostomy. A linear stapler is used for the jejuno-jejunal anastomosis. Transabdominal
port access number was reduced from 5-7 to 1-3 with 1-2 translumenal access ports.
Conclusion: This video shows the technical feasibility of Roux-enY bypass surgery in human cadavers
using a NOTES hybrid approach. Port numbers can be reduced. A combination of flexible with rigid endoscopic techniques devices offers specific advantages for components of this type of surgery. Changes in
instrument design are required to improve complex hybrid endosurgical procedures.
31.6
«Open heart surgery» – a video information for patients
M.K. Widmer, F. Angerer, R. Vogel, P.A. Berdat, T.P. Carrel (Bern)
Objective: In nowadays preoperative information is of increasing importance. At our institution an audiovisual system is in place, which allows the patient to get more technical informations and a deeper insight
in the type of surgery he is schedulded for.
Methods: This film was produced for cardiac surgical procedures and focuses on the indications and
technique for aortic valve replacement, coronary artery bypass surgery and replacement of the ascending aorta. All preoperative investigations and the management on the ward are shown. Technical details
of the extracorporeal circulation and an insight of the operation room and the technical equipement is provided. Visualization of the different steps during cardiac surgical procedures gives a better understanding
about the related morbidity and does motivate the patient to follow the behavioural recommendations
provided by the team in the early postoperative period.
Results: –
Conclusion: Audiovisual information systems substantially contribute to reassure and to inform the patient about the in-hospital period, gives a technical insight and allows to improve the level of information in
patients scheduled for cardiac surgery.
31.7
Congenital mitral insufficiency repair with the world’s smallest annuloplasty ring: video presentation
P.O. Myers, M. Cikirikcioglu, A. Kalangos (Genève)
Objective: The last step of mitral valve repair procedures in adult patients is described as the implantation
of the annuloplasty ring for annulus remodelling. Because implantation of the classic, nondegradable
annuloplasty rings may cause iatrogenic stenosis secondary to the ring itself as the child grows, there is
no appropriate size for pediatric population in the market except the biodegradable ring (Biodegradable
Mitral Annuloplasty Ring- BioringÂ®/Lonay, Switzerland). We present in this video presentation repair of a
congenital mitral insufficiency with world smallest mitral annuloplasty ring.
Methods: A 21-month-old boy, weighing 10.5 kg, was referred for heart failure due to severe mitral regurgitation. The preoperative echocardiogram showed decreased left ventricular ejection fraction, a dilated
left ventricle and severe mitral regurgitation from annular dilatation. Because of limited left ventricular
function, the patient underwent urgent mitral valve repair. At operation, the valve was structurally intact
and surgical analysis confirmed the suspicion of Carpentier type I mitral regurgitation. The anterior leaflet
surface was measured and the appropriate mitral biodegradable annuloplasty ring was choosen (size
no. 16). The annuloplasty ring was implanted according to intra-annular implantation technique.
Results: On surgical testing, there was no residual mitral regurgitation. The aortic cross-clamp and extracorporeal time was of 18 and 28 minutes. Per-operative transesophageal echocardiography showed
good coaptation of the leaflets, trivial mitral regurgitation, with no significant trans-mitral gradient, and
improved left ventricular ejection fraction. The hospital stay was uneventful.
Conclusion: Biodegradable mitral annuloplasty rings allow simple, fast, effective mitral repair in children.
Once implanted, the ring material is degraded by hydrolysis and replaced by fibrous scar tissue which
allows normal growth of the valvular orifice. Implantation of the material into the annulus prevents to
use of anticoagulant treatment. Intra-annular implantation keeps the possibility for re-repair operations
without creating dense adhesions and fibrosis on the annulus, which may occur after mitral plication
annuloplasty with Teflon pledgets.
31.8
Tricuspid valve repair with a biodegradable annuloplasty ring for Ebstein’s anomaly
M. Cikirikcioglu, P.O. Myers, E. Pektok, A. Kalangos (Genève)
Objective: Ebstein’s anomaly is a malformation of the tricuspid valve and right ventricle that is characterized by adherence of tricuspid leaflets to the underlying myocardium (mainly the anterior leaflet), downward displacement of the septal and posterior leaflets, dilatation of the atrialized portion of right ventricle
and dilatation of the right atrio-ventricular junction. The goals of surgery for Ebstein’s anomaly repair are
to treat both valvular and right ventricular dysfunction. Reinforcement of the tricuspid annulus by an annuloplasty ring is advised for older children and adult patients, but not for small children because it can
induce iatrogenic stenosis secondary to child growth. We share in this video our technique for Ebstein’s
repair combined with the implantation of a biodegradable ring, the only annuloplasty ring available for
pediatric sizes.
Methods: Six year-old boy was transfered to our center with the diagnosis Ebstein’s anomaly, type B. The
preoperative echocardiogram showed limited tricuspid anterior leaflet mobility, severe tricuspid regurgitation and good right ventricular function. After aorto-bicaval cannulation and crystalloid cardioplegic
arrest, the right atrium was opened. The anterior and posterior tricuspid leaflets were detached from the
annulus, and the adherences between leaflets and right ventricular free wall were resected. After longitudinal plication of the atrialized right ventricular segment, the anterior leaflet surface was measured to
choose the proper size of annuloplasty ring. A size 24 biodegradable tricuspid ring was implanted into the
annulus. The anterior and posterior leaflets were reattached to the annulus using the clockwise rotation
technique.
Results: The per-operative surgical control showed good closure of the tricuspid valve with rotated anterior
leaflet. Per-operative echocardiographic control showed trivial tricuspid regurgitation.
Conclusion: Reinforcement of the tricuspid annulus by an annuloplasty ring is important in order to preserve an efficient long-term tricuspid repair. On the other hand, preservation of the growth potential of the
tricuspid annulus is important in order to prevent iatrogenic stenosis secondary to child growth. The only
available annuloplasty ring for pediatric sizes is the biodegradable ring, which is degraded by hydrolysis
after implantation, replaced by fibrous scar tissue, which allows normal growth of the valvular orifice. Tricuspid annuloplasty with an annuloplasty ring is easy, fast and effective. We suggest this equipment may
help to improve effective tricuspid valve repair for Ebstein’s anomaly in adults as well as in children.
Cardiac Surgery
34
34.1
New device for myocardial intra-operative laser and cell therapy: feasibility & survival assessment
B.H. Walpoth, M. Jaconi, J.W. Liu, T. Laumonier, J. Menetry, M. Lepetit Coiffe, J.C. Tille, E. Pektok, M. Cikirikcioglu, S. Osorio-da Cruz, J. Vallee, A. Kalangos (Genève)
Objective: Trans-myocardial laser revascularisation (TMLR) has shown beneficial effects mainly based
on neo-angiogenesis. Combining this intra-operative procedure with cell therapy may have a synergistic
effect. Our aim was to evaluate a new laser and cell application device for intra-operative use.
Methods: The study included 5 pigs (3 acute-2 chronic surviving 5 days). In each pig six laser and cell
applications (4-MIO cells per injection) were performed on the beating left ventricle, namely: laser only,
laser+cells through the laser channel, laser+cells through the hand-piece needle delivery, laser+dual
injection, hand-piece needle delivery only, and hand injection. The following cell types were used: mouse embryonic stem cells (n=1), autologous bone marrow stem cells (n=1) and autologous expanded
skeletal myoblasts (n=1). In two control hearts China ink dye was injected. Cell labelling was achieved
by GFP and PKH26 dye. Quantitative assessment of skeletal myoblasts was performed with thymidine
radio-labelling. In addition, iron-loaded mouse embryonic stem cells were injected in two additional pig
hearts in vivo and examined by magnetic resonance imaging (MRI) ex vivo (Philips 1.5T).
Results: Histology showed necrosis around the laser channel and a more homogenous spread of injected cells was seen when using the hand-piece needle delivery system when compared to the other
described techniques. Few viable cells were found by immuno-fluorescence for all application modes.
The quantitative yield of radio-labelled myoblasts was 3.4% at 5 days. Injected iron-loaded cells were
easily located by 3D MRI.
Conclusion: The newly developed laser and cell application device was easy, safe and fast to use and
combines the option of TMLR with a precise and rapid cell application. The results from our pilot study
show best cell delivery through the new device even when using different cell types. New non-invasive
cell tracing techniques, such as MRI, will allow us to follow the survival and homing of transplanted cells
repeatedly, and over time, without animal sacrifice.
34.2
Absorbable annuloplasty ring in the tricuspid position: initial clinical experience in adult patients
P.O. Myers, A. Panos, M. Cikirikcioglu, A. Kalangos (Genève)
Objective: We present our initial clinical experience with an absorbable annuloplasty ring in the tricuspid
position.
Methods: Patients undergoing tricuspid annuloplasty alone or combined with other cardiac operations
were prospectively included between September 2004 and December 2006 and followed with transthoracic echocardiography. Adults with Ebstein‘s anomaly and children were excluded. Primary endpoints
were death and severe tricuspid regurgitation (TR) requiring reoperation for valve replacement. Secondary
endpoints were perioperative complications and relapse of severe TR.
Results: 32 patients (17 males) with a median age of 44 years old (range 16-81) underwent tricuspid
valve annuloplasty, 22 for functional tricuspid regurgitation, 7 for post-rheumatic TR, 1 for tricuspid endocarditis, 1 for Barlow TR and 1 for congenital TR. Median CPB and aortic cross-clamping was 81 (range
25-250) and 41 (range 0-180) min respectively. There were three early deaths, not related to the tricuspid
valve repair. Two patients required reoperation for tricuspid valve replacement. On discharge, 26 patients
had no or mild TR (grade ≤ I) and 1 had moderate TR (grade II) with no tricuspid stenosis. Median follow-up was 21 months (range 12-38 months). One patient was lost to follow-up. One patient developed
asymptomatic moderate TR. The remaining 25 patients had no or discrete TR.
Conclusion: Tricuspid valve surgery remains challenging and the optimal surgical strategy is controversial. Early results with a biodegradable ring in the tricuspid position seam acceptable and safe. Implantation
is simplified, possibly reducing cardiopulmonary bypass. Mid term results appear adequate, but further
investigation in a prospective randomized study comparing biodegradable ring, de Vega, and non-absorbable ring annuloplasty, is required.
34.3
Initial clinical experience with the admiral oxygenator is adult patients
E. de Stefano, D. Delay, J. Horisberger, L.K. von Segesser (Lausanne)
Objective: The Eurosets Admiral is new microporous hollow fiber oxygenator with an integrated heat exchanger and hardshell reservoir. Its characteristics include low surface area (1.34 m2) and static priming
volume (190 ml) and a separated cardiotomy reservoir to easily allow suction blood separation. This study was undertaken to evaluate, blood path resistance and blood trauma in clinical use, with and without
shed blood separation.
Methods: 30 patients (21 men) with a mean age of 68Â±10 years and a mean body surface area of 1.83
Â± 0.18m2 were operated between march and december 2007. Patients were separated in 3 groups,
group 1 : valve surgery (11 patients, 7 aortic valve replacement, 2 mitral valve repair, 2 mitral valve replacement). Group 2 (9 patients) CABG without suction blood separation and group 3 (10 patients) :
CABG with suction blood separation. In group 3, suction blood was treated using a cell saver device at the
end of the procedure. The three group of patients were equivalent in all terms except body surface area,
group 1 1.74Â±0.16m2 vs group 3 1.94Â±0.17m2 (p=0.01). Several parameters including laboratory tests
including free plasma hemoglobin, LDH, platelets, white blood cells and hemoglobin were measured before CPB, 15 minutes after CPB, at declamping and after the end of bypass. Normalized ratio of parameters were obtained by dividing the post CPB value by the baseline value.
Results: Theorical flow could be easily achieved in all patients. Pressure drop through the oxygenator
averaged 88Â±13 mmHg at 4 l/min and 109Â±12 mmHg at 5 l/min. Cardiopulmonary bypass time
was comparable in all groups (74Â±16 vs 73Â±22 vs 75Â±15 min, p = 0.47, 0.44, 0.41) All patients
survived the operation with no major complications. During bypass, free plasma hemoglobin rose in all
three groups but significatively less in the separation group (normalized ratio 12.2Â±6.6 vs 16.4Â±12.4
2.3Â±2.3, p=0.25, 0.02,
Conclusion: In this initial clinical experience the admiral oxygenator could be used safely. Low membrane
surface area resulted in slightly elevated pressure drops without adverse effect. Suction blood separation
was easily performed and allowed diminution of blood trauma as reflected by significative lower levels of
free plasma hemoglobin and LDH in this group.
34.4
Advances in vacuum assisted closure therapy for the treatment of poststernotomy mediastinitis: VACinstill system
S. Karaca, B.H. Walpoth, A. Kalangos (Genève)
Objective: Poststernotomy mediastinitis, also called deep sternal wound infection, is one of the most
feared complications in patients undergoing cardiovascular surgery. The incidence of poststernotomy
mediatinitis is fortunately very rare, between 1%-3%, but shows a significant mortality, between 10%-25%.
The conventional forms of treatment involve surgical revision, open dressing and daily sternal lavage.
Vacuum-assisted closure therapy for treatment of sternal wound infection is a common therapy since
1996. This wound-healing technique is based on a local negative pressure which increases the microcirculation in the wound. The Vacuum-assisted closure (VAC) system has recently been modified, allowing
intermittent instillation of antiseptic or antibacterial fluids into the wound. This VAC-Instill therapy system is
an innovative method that combines the benefits of VAC and instillation therapy to help promote wound
healing in cases of mediastinitis.
Methods: Of 4 male patients (mean age 66 years), 3 underwent cardiac surgery and 1 was operated for
a dissected ascending aortic aneurysm. Acute purulent sternal infection occurred in all patients. Sternal
wound infection became evident on average at 9 days after surgery, associated with dehiscence, sternal
instability and mediastinitis in all cases. The cultures most commonly identified were staphylococus aureus in two cases, mycoplasm in one and one patient showed infection with E.coli. Opening of the sternum,
prompt irrigation and debridement were performed on all cases. The new VAC-instill system therapy, with
intermittent instillation and lavage with antiseptic fluids, was applied immediately after diagnosis. The
antiseptic (Lavasept®) fluid instillation was 250cc every 8 hours regulated by the VAC-Instill system and
VAC was changed was every 4-5 days.
Results: The VAC-Instill therapy lasted on average 18+/-2 days, a median of 5-6 changes were necessary
until the definitive closure of sternum. There were no deaths, and all patients could leave the hospital
immediately after the closure of the sternum after 25+/-2 days.
Conclusion: The new VAC–Instill system is useful in the treatment of mediastinitis for the following reasons: (1) it is a temporary wound care technique before reclosure of the sternum; (2) intermittent instillation of antiseptic fluid supports the cleaning and drainage of the wound bed and the removal of infectious
material; (3) it reduces the number of dressing changes, and the need to perform daily open surgical
wound cleaning in the operating room under general anaesthesia; (4) prevents shear stress of an open
sternum. In the 4 cases we treated with the VAC-Instill system, we saw rapid clinical improvements and
good end results in all patients. Thus, this method could open a new generation of treatment for poststernotomy mediastinitis.
49
34.5
Histiocytosis X and right atrial thrombus in a 3 years old child
M. Hurni, S. Di Bernardo, N. Sekarsky, E. Meijboom, P. Stücki, M.H. Perez, M.A. Bernath, L.K. von Segesser
(Lausanne)
Objective: Histiocytosis X is a complex and poorly understood entity. Cardiac lesions associated with a
proliferative histiocytic disorder have been reported very rarely. We present a 3 years old child treated for
histiocytosis with a right atrial thrombus
Methods: A 3 years old child was admitted to our intensive care unit (ICU) with high fever and pancytopenia after multiagent chemotherapy. The initial multiagent chemotherapy was started 3 months before because of a complex presentation of histiocytosis X. The child was diagnosed as histiocytosis X
with two populations of histiocytes one with Langerhans’-cell histiocytosis involving bones and central
nervous system. The other histiocyte population had no positive staining for HLA marker CD1a and the
protein S100 (distinguishing Langerhans’-cell histiocytosis). During the ICU stay, echocardiography was
performed and a right atrial mass of 3x1cm was detected. Anticoagulation was started and neutropenia
corrected spontaneously after one week. During this week, the atrial mass increased despite anticoagulation. Decision was made to remove the atrial mass on cardiopulmonary bypass. Operation was performed on normothermic conditions. Right atrium was opened and a thrombus of 3.5x1 cm removed cloth
to Eustachian valve. The basis of the thrombus was welded to the wall so atrial wall was removed together
with the thrombus. The postoperative course was uneventful. Examination of the endocardic side showed
fibrinous thrombus. Examination of the atrial wall showed under the epicardium many histiocytes with
inflammatory cells with giant multinucleated cells. Staining for HLA marker CD1a and the protein S100
for the histiocytes was negative.
Results: Inflammatory thickening of atrial wall can be caused by the histiocytes beneath the epicardium
leading to thrombus formation on the endocardial side.
Conclusion: Histiocytosis X is a rare and complex disease with a very few cardiac involvement. Nevertheless when the disease is “disseminated” heart lesions as thrombus can be encountered.
little is known about the early postoperative course on the intensive care unit (ICU) in these patients. Aim
of the present study was to asses early outcome on the ICU and to look after risk factors for prolonged
ICU recovery.
Methods: ICU-charts and in-hospital data of 112 consecutive patients who underwent surgery for AADA
have been analyzed. Patients were divided into 3 groups, according to the duration of ICU-stay: Group 1 (<
25h): 32 pts (28.6%); Group 2 (25 to 80h): 50 pts (44.6%); Group 3 (>80h): 30 pts (26.8%).
Results: Patients from group 3 were older (65.8 y vs. 57.1 y; p<0.05) and suffered more frequently from
malperfusion syndrome (MPS) (40.0% vs 18.8%; p<0.05) than patients in group 1. Prolonged recovery in
group 3 compared to group 1 was due to delayed extubation (96.8h vs. 12.5h; p<0.05), hemodynamic
instability, renal insufficiency and a higher incidence of cerebrovascular incidents (13.3% vs 0%; p<0.05).
Duration of deep hypothermic circulatory arrest (25.1min vs. 21.2min; p=ns) and aortic cross clamping
time (91.6min vs. 80.4min; p=0.07) tend to be longer in group 3 compared to group 1. Modality of cerebral protection did not differ between the 3 groups.
Conclusion: In nowadays early postoperative course on the ICU after surgery for AADA is in the majority
of patients (73.2%) uneventful and not affected by duration of surgery. However, older patients, suffering
from preoperative MPS with postoperative multi-organ failure are very demanding.
Visceral Surgery
35
35.1
Single midline working port for TEP inguinal and crural hernia repair
P. Bucher, F. Pugin, I. Inan, F. Ris, Ph. Morel (Genève)
34.7
Objective: Study aim was to evaluate the feasibility of single working port laparoscopic TEP hernia repair
and to analyze if reduced disposable cost is not counterbalanced by longer operative time and indirectly
induced cost.
Methods: Prospective longitudinal study evaluating the feasibility and validity of single working port for
totally extraperitoneal laparoscopic (TEP) groin hernia repair. For single working port TEP one umbilical
optic port and a midline 5mm port were used. 44 consecutive cases of single working port TEP were
compared to the previous standard hernia repair performed by the same surgeon in matched patients.
Primary end-point evaluated was operative time. Secondary end-points were operative cost, per- and postoperative complications, and rate of conversion to standard TEP hernia repair (which happened in 14
additional cases not included with the 44 single working port TEP reported here).
Results: Single working port TEP and conventional TEP repair groups were similar in terms of patient’s
age, unilateral or bilateral hernia, type of hernia (indirect, direct and crural). A higher number of patients
in the single working port group had a previous history of hernia repair or Mc Burney incisions. Median
operative time was 35 (24-54) min for all single working port TEP repair and of 39 (26-69) min for conventional TEP group (p=0.042). Median operative time for unilateral repair was of 31 (24-46) min for
single working port TEP compared to 36 (26-48) min for conventional TEP group (p=0.039). No per- or
post-operative complications were recorded in the single working port group.
Conclusion: Single working port laparoscopic TEP hernia repair is easily performed by surgeon trained
for laparoscopic hernia repair and safe. The rate of conversion to standard laparoscopic TEP repair is low
(less than 30%). The cost of TEP repair can be reduced by this approach as less disposable materials are
needed and operative time is not increased but even decreased.
Cardiopulmonary bypass (CPB) in the rat with a new miniaturized hollow fiber oxygenator
G.D. Cresce1, F. Innocente1, D. Mugnai1, M. Tessari2, A. Mazzucco2, A. Kalangos1, G. Faggian2, B.H. Walpoth1 (1Genève, 2Verona/IT)
35.2
34.6
Life-threatening pulmonary embolism associated with a thrombus straddling a patent foramen ovale
P.O. Myers, A. Panos, A. Fassa, A. Kalangos (Genève)
Objective: A biatrial thrombus straddling a patent foramen ovale (PFO) is rare. The optimal management
is controversial. This report offers and additional report and brief review of the literature.
Methods: An observation of a PFO-straddling thrombus is presented and a brief review of the literature
is provided.
Results: A 72 year-old female presented with paroxysmal dyspnea. Transthoracic echocardiography
showed distended right heart cavities, pulmonary artery hypertension and a thrombus in the right atrium
passing through the PFO into the left atrium. Urgent surgical embolectomy confirmed an 11.5 cm serpentine biatrial thrombus and allowed PFO closure and bilateral pulmonary embolectomy. Postoperative
recovery was uneventful.
Conclusion: The risk of systemic embolization during thrombolytic or heparin treatment for biatrial thrombus makes most authors recommend surgical or interventional thrombectomy and PFO closure. Given
the limited number of cases, there is no evidence that any of the treatment strategies provide a better
survival.
Objective: CPB is an essential component of cardiac surgery, with still unknown device/patient interactions. In order to evaluate the response of CPB to hemodynamic, biochemical, inflammatory, as well as
thermo- pharmacodynamic interactions, a novel miniaturized oxygenator with controlled and standardized specifications has been developed together with an improved surgical central cannulation technique.
Methods: A hollow-fibre small priming volume (6.3ml) oxygenator was manufactured according to specifications resulting from engineering, heart surgery and perfusionist expertise (Dideco-Sorin Group, Italy)
with the following characteristics: Gas Exchange Surface-450cm2, Heat Exchange Surface-16cm2. The
oxygenator was tested in vitro and in vivo in 5 anaesthetised, ventilated, open-chest rats using a miniaturized roller pump and heat exchanger. Pressures were monitored in the animal, before and after the
oxygenator. Central venous cannulation through the right atrium, and aortic cannulation, through the
carotid artery, were used.
Results: In vitro: blood oxygenation increased 10-fold (from room air to 100% FIO2) and PCO2 removal
was 2.5-fold. In vivo: CPB was performed without blood prime for 60mins (no ventilation) maintaining
stable haemodynamics. A maximal blood flow rate of 124ml/min/kg was obtained. Arterio-venous PO2
gradients were 10-fold (FIO2@100%) with only small variations when changing blood flow rates.
Conclusion: The results obtained with this new, standardized and miniaturized hollow fibre oxygenator, new cannulation technique and CPB circuit, achieves optimal gas transfer with small asanguinous
priming volumes. This study opens new potentials for various CPB-related study protocols in the small
animal.
34.8
Early postoperative course on the intensive care unit after surgery for acute type A aortic dissection
S. Descombes, F.F. Immer, M. Stalder, L. Englberger, S. Jakob, T. Carrel, F.S. Eckstein (Bern)
Objective: Several risk factors for poor outcome after surgery for AADA have been described, however
50
Early robotic learning curve in comparison to conventional laparoscopy
M. Hagen, I. Inan, P. Schindler, F. Pugin, Ph. Morel (Genève)
Objective: Due to improved ergonomics, dexterity and 3-D-vision, robotic surgery is supposed to be easier
than conventional laparoscopy. Therefore, initial robotic performance should be better and learning faster.
We have tested the above hypothesis in both inexperienced people and laparoscopic surgeons.
Methods: 34 individuals were tested for initial robotic and laparoscopic performance and learning progress. Group1 included 18 surgically inexperienced students and doctors. Group 2 included 16 experienced laparoscopic surgeons. Each proband performed an easy, a medium and a difficult tasks both
with the da Vinci® robot and instruments of conventional laparoscopy 10 times. Times and errors were
taken and an overall score allocated for the robotic and laparoscopic performance. The learning progress
was defined as the difference between the first and the last performance in both methods.
Results: Group 1 performed all 3 of their allocated tasks significantly better using the da Vinci robot when
compared to their performance using conventional laparoscopic equipment (p<0,05). Group 2 performed significantly better with the robot for the medium and the difficult task in comparison to laparoscopy
(p<0,05). Differences were not significant for the easy task. No significant differences between group 1
and 2 were found when performing the easy task both with the robotic and laparascopic equipment.
There were no significant differences between the two groups performing the medium task with the robot, while group 2 was superior to group1 in laparoscopy for the same task (p<0,05). For the diffucult
task, group 2 performed significantly better than group 1 with both robotic and laparoscopic equipment
(p<0,05). Learning progress in laparoscopy of both groups was greater for all tasks when compared to
the robotic learning progress. Group 1 showed a significantly greater progress in laparoscopy compared
to robotics for the easy, and group 2 for the difficult task (p<0,05). Furthermore, group 1 demonstrated
more progress using the robot for the difficult task than group 2 (p<0,05).
Conclusion: The data support the conclusion that the performance of inexperienced individuals using the
da Vinci® robot is superior to their performance with conventional laparoscopic equipment. The difference
in performance of inexperienced individuals and experienced laparoscopic surgeons is less evident while
using the robotic system when compared to conventional laparoscopy, but experienced laparoscopists
are superior in difficult tasks. Most likely due to this excellent performance, initial learning progress with
the robot is minor compared to conventional laparoscopy. However, the robot helps beginners to learn
faster than laparoscopic surgeons for difficult tasks.
35.3
Preemptive conversion does not increase morbidity of laparoscopic colorectal resection: 10 years experience of the SALTS database.
D. Hahnloser, D. Dindo, M.K. Müller, M. Schäfer (Zürich)
Objective: Conversion increases morbidity of laparoscopic colorectal resections. The aims of this study
were to analyze risk factors and causes of conversion and to review the outcomes of a nationwide prospective multicenter database.
Methods: Analysis of all patients undergoing elective laparoscopic colorectal resections from 1995-2005
based on the prospective database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS).
Results: 3830 patients with a mean age of 61.6 years (±13) and a mean BMI of 26.3 kg/m2 (±4.5)
underwent laparoscopic right colectomy (8%), sigmoid/left (74%), rectal (16%) or other resection (2%).
Intraoperative complications occurred in 9% and could be managed laparoscopically in 58%. Overall
conversion rate was 14.9%. Risk factors for conversion were male gender, ASA III+IV, limited laparoscopic
experience of the surgeon, but not increased patients’ age or BMI. 48% of conversions were preemptive
and 52% were reactive (due to uncertainty in 58%, complications in 38% and 4% various). Surgical and
general (cardiac, pulmonal) complications significantly increased with conversion from 11.4% to 21.8%
(p<0.001) and from 9.3% to 14.9% (p<0.001). However, if conversion was preemptive, surgical and general morbidity was not significantly different to non-converted patients (13.0% and 9.1%, respectively).
Conversion significantly prolonged hospitalization regardless if it was reactive or preemptive (14.7 and
13.3 vs. 10.3 days, respectively). Over time, the overall conversion rate decreased from 26.3% in 1995 to
12.6% in 2005. Although more conversions were reactive (31% in 1995 and 72% in 2005), surgical and
general morbidity constantly decreased (overall morbidity of 23% in 1995 to 16% in 2005; p=0.001).
Conclusion: Preemptive conversion does not increase morbidity of laparoscopic colorectal resection, but
prolongs hospitalization by an average of 3 days. Over time, surgeons tended to convert later or more
reactively, however without increasing morbidity.
35.4
Surgical management of acute small bowel obstruction from intestinal adhesions – What is the role of
laparoscopic surgery?
F.C. Grafen, V. Neuhaus, M. Turina, O. Schöb (Schlieren)
Objective: Acute small bowel obstruction (SBO) from abdominal adhesions is an accepted indication
for explorative laparotomy despite several reports of successful laparoscopic management in distinct
patient subgroups. The aim of this study is to compare our experience of laparoscopic management of
SBO to that of patients who had to be converted to open surgery and those who were primarily treated
by explorative laparotomy.
Methods: All patients admitted with SBO secondary to intraabdominal adhesions were enrolled and grouped into the three following subgroups: 1. Patients who were successfully managed by laparoscopic surgery, 2. patients in whom laparoscopic adhesiolysis failed and who had to be converted to open surgery,
and 3. patients who were initially managed by explorative laparotomy and open adhesiolysis. Univariate
groupwise comparisons were performed using SigmaStat® 3.11.0 and results considered significant at
p<0.05.
Results: In total, 93 patients were enrolled (mean age 61 ± 1.9 years, 67% female). 66 patients could
be managed by laparoscopy alone, 24 patients had to be converted from laparoscopic to open surgery,
and finally, 3 patients were treated by explorative laparotomy without prior laparoscopy. No differences
were observed with respect to age, gender, time until operation, and infectious parameters upon admission. The number of prior abdominal operations and ASA class were higher in patients requiring open
surgery (p<0.01). Also, patients who could be managed laparoscopically had a higher percentage of
simple adhesions (57%), whereas all patients treated by primary or secondary laparotomy suffered from
multiple, extensive adhesions (p<0.001). Operative time was shortest in the laparoscopy group (74.3 ±
4.4 minutes vs. 150.8 ± 13.8 minutes [converted] and 113.3 ± 13.8 minutes [open surgery], all p<0.01).
Furthermore, patients treated laparoscopically stayed on the ICU the shortest (0.8 ± 0.2 day vs. 3.0 ± 1.5
days [converted] and 6.3 ± 1.0 days [open], all p<0.05), and were discharged home after only 8.6 ± 0.9
days as opposed to 15.1 ± 2.6 days in the “converted” group and 20.7 ± 1.4 days in the “primarily open”
group (all p <0.01). Overall mortality was 6%, regardless of operative technique.
Conclusion: Patients who could be managed by laparoscopy alone had the most favourable postoperative course and could be discharged home earlier than patients treated by explorative laparotomy.
However, the majority of patients in the laparoscopy group suffered from “simple” abdominal adhesions
following fewer prior abdominal operations that were technically easier to treat. In patients with more
extensive adhesions, higher ASA class, and more than two prior abdominal operations, laparotomy was
mandatory to achieve an equally satisfactory outcome. Apart from prolonged operative time, initial laparoscopy seems advisable in the light of potentially improved outcome even in patients that may have to be
converted to secondary laparotomy.
35.5
A new techniques for totally intracorporeal laparoscopic colorectal anastomosis using circular stapler
P. Bucher, F. Pugin, N.C. Buchs, P. Gervaz, Ph. Morel (Genève)
report a new laparoscopic technique for totally intracorporeal colorectal circular anastomosis (TLCCA)
using circular stapler.
Methods: Preliminary experience using TLCCA in 13 patients scheduled for laparoscopic left colectomies
(7), sigmoidectomy (5) and low anterior resection (1). Median age of patients was 69 (51-86) years and
median BMI 25 (20-34).
Results: Side to end colorectal anastomosis through TLCCA was feasible in all patients, without conversion to standard laparoscopic approach or open surgery. Median operative time was 125 (109_173) min.
Median time from anvil insertion into abdominal cavity to anastomosis was 12 (10-21) minutes. Specimen length was 33 (26-52) cm and number of lymph node recovered in cancer patients was 21 (15-29).
No post-operative complications were recorded with a median hospital stay of 5.5 (4-9) days.
Conclusion: Side to end anastomosis can be easily and safely performed using conventional circular
stapler through TLCCA. TLCCA is performed using four laparoscopic port without additional skin incision
(except troccars incision) and allow retrieval of surgical pieces through a specimen bag.
35.6
Who should do NOTES? Initial endoscopic performance and early learning curve of laparoscopic surgeons and non-surgical individuals in comparison to experienced endoscopists
O.J. Wagner1, M. Hagen2, F. Pugin2, J.H. Fasel2, Ph. Morel2, D. Candinas1 (1Bern, 2Genève)
Objective: Due to well trained manual dexterity, spatial orientation and hand-eye alignment, laparoscopically experienced surgeons – even without endoscopic experience - should master very quickly the
handling of endoscopic equipment. Initial performance should be superior when compared to individuals
without surgical training and learning curve rapid. Endoscopically inexperienced laparoscopic surgeons
may even quickly reach the endoscopic dexterity of endoscopists.
Methods: 25 individuals were tested for endoscopic dexterity. Group 1 included 5 endoscopists. Group
2 included 10 laparoscopic surgeons without endoscopic experience. Group 3 contained 10 medical
students without endoscopic and surgical experience. Each individual performed 10 times an easy, a
medium and a difficult task with endoscopic equipment on a NOTES skills-box. Time and errors were
meassured, an overall score allocated and evaluated statistically.
Results: Group 3 performed all 3 of their allocated tasks significantly worse when compared to group 1
and 2 (p<0,05). No differences were detected between the performances of group 1 and 2 for the easy
and the medium task (p>0,05). Group 1 performed the difficult tasks significantly better than group 2
(p<0,05). Group 2 demonstrated a very rapid learning curve between the first and tenth performance with
a significantly better result for the tenth time of performance when compared to the first (p<0,05).
Conclusion: The data support the conclusion that endoscopically inexperienced laparoscopic surgeons
learn very quickly the handling of endoscopic equipment. Their initial performance is superior when compared to individuals without any surgical training. Furthermore, intitial performance is similar when compared to trained endoscopists for easy and tasks of moderate difficulty. However, endoscopists are still
superior in handling endoscopic material for complex tasks when compared to endoscopically untrained
surgeons. The data therefore suggest that laparoscopic surgeons are not disadvantaged by their lack of
endoscopic experience and - due to their surgical experience - should perform NOTES.
35.7
Laparoscopic cholecystectomy as a standardized teaching operation: a comparison of operative complications and short-term outcome between surgical residents and attending surgeons in 1220 patients
R. Fahrner, M. Turina, V. Neuhaus, T. Köstler, O. Schöb (Schlieren)
Objective: Standardized, efficient surgical training is increasingly confronted with the public demand for
high quality of surgical care in modern teaching hospitals. The aim of this study was to compare perioperative morbidity and mortality of laparoscopic cholecystectomy (LC) as a highly standardized teaching
operation when being performed by junior and senior surgical residents (RS) as opposed to those performed by attending surgeons (AS), in a hospital with high percentage of laparoscopic operations.
Methods: 1220 LC were performed in a university-affiliated Swiss community hospital between 1999 and
2006. There were 788 (65%) female and 432 (35%) male patients, with an average age of 55 years
(range 16-93 years); 874 operations were performed electively, 346 cases were urgent operations. All
LC performed by resident surgeons were assisted by attending surgeons or chief residents. Intraoperative
cholangiography was routinely performed. Observed parameters were the duration of operation and of
hospital stay, 30-day perioperative morbidity and mortality, and readmissions. Results are stated as mean
± SEM, with p<0.05 defined as statistically significant.
Results: Overall length of operation was 92 ± 2 minutes for RS vs. 80 ± 2 minutes by AS (p<0.001). Elective operations were shorter (91 ± 2 [RS] vs. 76 ± 2 [AS] minutes, p<0.001) than urgent operations (96
± 3 [RS] vs. 90 ± 3 [AS] minutes, p=0.3). Length of hospital stay was shorter in patients treated by RS as
compared to those treated by AS (elective LC: 5.2 ± 0.3 days [RS] vs. 6.7 ± 0.2 days [AS], p<0.001; urgent
LC: 6.8 ± 0.6 days [RS] vs. 8.2 ± 0.5 days [AS], p=0.1). Intraoperative complications occured in 4.2%, and
were independent of surgeon’s experience. Bile duct lesions occurred in 0.2% of all patients. Conversion
to an open cholecystectomy for technical difficulties was performed in 24 patients (1.9%). Thirty day morbidity was 8.7% in urgent LC versus 3.3% in elective LC (p<0.001). Overall mortality was 0.4% in elective
LC and 1.9% in urgent LC (p>0.001), again independent of surgical expertise.
Conclusion: Surgical residents are able to perform LC under appropriate supervision with results comparable to those of experienced surgeons. No differences could be detected with respect to perioperative
morbidity or mortality; in particular, serious surgical complications such as bile duct injury are rare and
are again independent of surgeon’s’ experience. A structured residency quality control program can improve the quality of surgical care and pinpoint weaknesses of surgical training at individual institutions.
Objective: A number of surgical techniques for colorectal anastomosis have been described for laparoscopic left-sided colectomies. Due to complexity of these procedures, open preparation of the proximal
bowel for circular stapler anastomosis, through Pfannenstiel incision has become the gold standard. We
51
35.8
Hiatal hernias with paraesophageal involvement – do we need a fundoplication?
G.R. Linke1, F. Marra1, B.P. Müller-Stich2, J. Borovicka1, R. Warschkow1, J. Lange1, A. Zerz1 (1St. Gallen,
2
Heidelberg/DE)
Objective: Laparoscopic Fundoplication (LF) is recommended as complement to the repair of hiatal hernias (HH) with paraesophageal involvement to reduce recurrence. Today the implementation of mesh reinforcement leads to a lower rate of recurrence. Considering this and as fundoplication-related side-effects
are frequent, it is not clear if LF is necessary. We evaluated the outcome of patients with paraesophageal
involvement of HH one year after laparoscopic mesh-augmented hiatoplasty (LMAH).
Methods: 37 consecutive patients (24 females; median age 66 years) with paraesophageal and mixed
HH were treated with LMAH and recorded prospectively in the period of 2003 to 2006. Surgery included
hernia reposition, crural repair, circular polypropylene mesh reinforcement and anterior cardiopexy. Preoperatively and one year postoperatively, HH and esophagitis were diagnosed with upper GI endoscopy.
Symptoms were evaluated using a modified gastrointestinal symptom rating scale questionnaire.
Results: 10 (27%) patients had a paraesophageal and 27 (73%) a mixed HH. Preoperatively esophagitis
was present in 20 (54%) patients. 30 (81%) patients were available for the one year endoscopic and 33
(89%) for the symptomatic follow-up. Endoscopy revealed 4 (13%) patients with recurrent axial HH. Four
(13%) patients still had esophagitis but of lower grade, whereas further 4 (13%) had developed new esophagitis. There were no mesh-related complications. The mean reflux score fell from 3.1 to 1.7 (p<0.01),
gasbloat from 3.6 to 2.1 (p<0.01) and dysphagia from 2.1 to 1.3 (p<0.01). All but one patient were able to
belch whereas vomiting was impossible for 2 patients. 94% of the patients assessed the operation result
as „good to excellent“ and would re-undergo the operation.
Conclusion: Laparoscopic repair of HH with paraesophageal involvement seems to be effective even
without fundoplication, if polypropylene mesh reinforcement is applied. The reduction of hernia recurrence
without fundoplication-associated side-effects leads to a symptom improvement. Long-term follow-up is
required to determine the true incidence of recurrence, reflux control and mesh complications.
35.9
Prospective quality of life assessment after laparoscopic resection for low rectal cancer
D. Steinemann, D. Dindo, P.-A. Clavien, D. Hahnloser (Zürich)
Objective: Laparoscopic resection of rectal cancer has gained attraction due to short-term benefits such
as faster recovery and lower morbidity compared to open resection. However, little is known about quality
of life after laparoscopic surgery for low rectal cancer.
Methods: Quality of life of patients undergoing laparoscopic resection for low rectal cancer (up to 10cm
from anal verge) was prospectively assessed. Patients completed validated questionnaires (EORTC
CR30, CR38 and a validated functional questionnaire) before laparoscopic resection, before closure of
temporary ileostomy as well as 6, 12 and 24 months after resection.
Results: 33 patients (23 males, 10 females) with a mean age of 62.6 years (+10.2) were included.
EORTC CR30 and CR38 scores, such as the global quality of life score were negatively influenced by
the protective ileostomy (if performed), however, returned to preoperative value already at 6 months (62
preop vs. 68 at 6 month; p=0.7) and remained at the same level at 24 month (69; p=0.5). Similar findings
were observed for the role functioning score (80 preop vs. 79 at 6 month, vs. 75 at 24 month; p=0.8) and
the social functioning score (78 vs. 80 vs. 74, respectively; p=0.9). The sexual enjoyment score tended
to be decreased at 6 months (64 preop vs. 50 at 6 month; p=0.09), however, improved and returned to
preoperative value at 24 month (70, p=0.35). Stool frequency per day remained stable with a median of
3 (range 1-10) at 6, 12 and 24 months after surgery. Although an increase in nocturnal defecation (38%
at 6 months and 75% at 24 months) and stool evacuation problems (73% at 6 months and 75% at 24
months) were noted, patients adapted to these problems. This adaptation resulted in an improvement
in the defecation problems perception score over time (from 30 preoperatively to 31, 28, 24, at 6, 12, 24
months, respectively; p=0.047). Feeling of incomplete evacuation was described at 6 and 24 months to
be occasionally in 41% and 50% and frequently in 32% and 25%,respectively (p=0.1). Median Wexner
incontinence score was 9 (range 0-18) at 6 months, 8 (range 0-18) at 12 months and 9 (range 0-16) at
24 months (p=0.5).
Conclusion: Laparoscopic resection for rectal cancer has no significant negative impact in patient’s
perception of quality of life and daily functioning shortly after and up to 2 years after surgery. Although
objective disturbances of defecation and incontinence are often reported during the first two years after
surgery, no negative influence on quality of life may be observed.
Research
43
43.1
Simvastatin reduziert die Endotoxin-Suszeptibilität nach Leberteilresektion
J.E. Slotta1, M.W. Laschke1, M.K. Schilling1, M.D. Menger1, H. Thorlacius2 (1Homburg-Saar/DE, 2Malmö/
SE)
Objective: Erweiterte Leberresektionen stellen häufig die letzte therapeutische Option für Patienten mit
ausgedehnten hepatobiliären Neoplasien dar. Jedoch führt der massive Verlust funktioneller Lebermasse
zu post-operativer Leberdysfunktion und steigert die Suszeptibilität für eine nachfolgende Infektion. Ziel
der vorliegenden Studie war zu klären, ob durch Behandlung mit dem HMG-CoA-Reduktase-Inhibitor Simvastatin der LPS-induzierte Leberschaden nach Leberresektion reduziert werden kann.
Methods: An männlichen C57BL/6-Mäusen mit einem Körpergewicht von 20-24g wurde eine 68%ige
Leberresektion in Ketamin/Xylazin-Narkose durchgeführt. 24h später wurde bei hepatektomierten Tieren
52
eine Endotoxinämie (E.coli-LPS; 5mg/kg, i.p.) induziert. Gleichzeitig erhielten die Tiere 20µg/kg oder
200µg/kg Simvastatin. Um die Beteiligung der HMG-CoA-Reduktase nachzuweisen, erhielten zusätzliche Tiere eine Kombinationsbehandlung mit Simvastatin und Mevalonat (10mg/kg). Hepatektomierte
Tiere dienten als nicht-endotoxämische Kontrollen, sham-operierte Tiere dienten als Negativ-Kontrolle. Zur
Analyse des LPS-induzierten Leberschadens wurde nach 6-stündiger Endotoxinämie die Serum-ALT-Aktivität gemessen. Die hepatozelluläre Apoptose und die Leukozyteninfiltration wurden histomorphologisch
quantifiziert.
Results: Hepatektomie führte zu einem signifikanten Anstieg der Serum-ALT (7.0±1.0 vs 0.5±0.1µkat/l;
p<0.05), sowie zu einer leichten leukozytären Infiltration (0.8±0.3 vs. 0.1±0.0 Leukozyten/HPF; p<0.05),
jedoch nicht zu hepatozellulärer Apoptose. Bei endotoxinämischen, hepatekomierten Tieren fand sich
ein 4-facher Anstieg der Serum-ALT (25.3±7.5µkat/l; p<0.05), sowie ein 14-facher Anstieg der Anzahl
infiltrierender Leukozyten (11.6±0.8 Leukozyten/HPF; p<0.05). Ebenso fand sich eine massive hepatozelluläre Apoptose (3.9±0.4 vs. 0.0±0.0%; p<0.05). Die Behandlung mit Simvastatin führte zu einer
Dosis-abhängigen Reduktion der LPS-induzierten ALT-Freisetzung (20µg/kg: 12.2±1.8µkat/l; 200µg/kg:
8.9±1.6µkat/l; p<0.05) und reduzierte Dosis-abhängig die Leukozyteninfiltration (20µg/kg: 6.4±1.6 Leukozyten/HPF; 200µg/kg: 3.8±0.8 Leukozyten/HPF; p<0.05). Ebenso verhinderte Simvastatin vollständig die Endotoxin-induzierte hepatozelluläre Apoptose (0.0±0.0%; p<0.05). Die zusätzliche Gabe von
Mevalonat, dem Produkt der HMG-CoA-Reduktase, hob die Simvastatin-vermittelte Protektion der Leber
vollständig auf.
Conclusion: Die vorliegenden Ergebnisse zeigen, dass Simvastatin nach ausgedehnter Leberresektion
die Restleber gegen Endotoxin schützt. Weiterhin geben unsere Ergebnisse Anhalt, dass die Simvastatinvermittelte Protektion durch die Inhibierung des HMG-CoA-Reduktase-Signalwegs erfolgt. Somit stellt Simvastatin einen möglichen neuen Ansatz zur Prävention des Leberversagens nach Leberresektion dar.
43.2
Transplantation of immortalized human hepatocytes improves survival without increase of native liver
regeneration in acute liver failure
A. Sgroi, G. Mai, Ph. Morel, R.M. Baertschiger, C. Gonelle-Gispert, V. Serre-Beinier, L.H. Bühler (Genève)
Objective: The aim of this study was to evaluate the impact of intraperitoneal transplantation of immortalized human hepatocytes on native liver regeneration in mice with fulminant liver failure.
Methods: Human hepatocytes were immortalized using lentiviral vectors coding for SV 40 large T antigen,
and telomerase. To prevent immunological damage, primary and immortalized human hepatocytes were
microencapsulated using alginate-polylysine polymers and transplanted intraperitonealy into mice with
acute liver failure induced by an overdose of acetaminophen (500mg/kg i.p.) followed by a hepatectomy
of 30% resulting in a reproducible survival of 20-30%. To analyze liver regeneration, we measured serum
levels of cytokines implicated in liver regeneration (TNFalpha, IL-6, HGF and TGF beta 1) by enzyme-linked immunosorbent assay, proliferating cell nuclear antigen (PCNA) expression and bromodeoxyuridine
(BrdU) incorporation in native liver tissue by immunohistochemistry at various time points
Results: In mice transplanted with empty capsules (n=10) or free primary hepatocytes (n=12) survival
remained unmodified compared to untreated mice (20%). In contrast, mice transplanted with encapsulated immortalized human (n=9) hepatocytes showed an improved survival of 55% (p<0.05). Serum
levels of TNF-a, IL-6, HGF and TGF-b1 were lower in mice transplanted with hepatocytes compared to
mice receiving empty capsules. This decrease was significant for IL-6 at 3h and for HGF at 72h (p<0.05).
Measurement of liver regeneration showed no significant difference between mice transplanted with hepatocytes compared to mice receiving empty capsules (PCNA expression: 20.6% versus 20.8% at 48h
and 8.3% versus 9.1% at 72h; BrdU incorporation: 21% versus 19% at 48h and 9% versus 9% at 72h,
respectively).
Conclusion: Intraperitoneal transplantation of encapsulated immortalized hepatocytes significantly improved survival of mice with acute liver failure, decreased the secretion of cytokines implicated in liver
regeneration, and did not modify native hepatocyte proliferation. These data suggest that intraperitoneal
hepatocyte transplantation provides life-supporting liver-specific metabolic functions, but has no impact
on native liver regeneration.
43.3
Cholestatic liver injury in mice – a pressure induced phenomenon – lessons learned from a new model
of mild cholestasis
S. Heinrich, P. Georgiev, W. Jochum, P.-A. Clavien (Zürich)
Objective: Cholestatic liver injury is a serious problem for liver surgery, and bile duct ligation (BDL) is the
standard model for research in cholestasis in mice. However, BDL causes severe tissue injury to murine
livers. Therefore, we established a new model of partial BDL (pBDL) with the intent to decrease the tissue
injury and to evaluate the mechanisms of tissue injury following BDL in mice.
Methods: Male C57Bl/6 mice (n=10/group) underwent median laparotomy and cholecystectomy followed by either BDL or pBDL. For pBDL, the ligation was placed around the bile duct and a 7-0 needle. This
needle was removed after secure ligation. After blood samples were taken from a tail vein 3, 5, 7, 10, 14
days after BDL/pBDL to determine serum levels of bilirubin, aspartat-amino-transferase (AST) and alkaline phosphatase (AP). For histologic experiments, additional mice (n=6/group) were harvested 1, 3 and
5 days after surgery. Hepatic necrosis formation was determined by morphometry on H&E slides, and cellular proliferation was assessed by Ki67 immunostaining. Biliary pressure was determined on day 3 after
pBDL/BDL (n=6/group) using a modified Servomed device. P-values <0.05 were considered significant
Results: From day 0 to 5, pBDL resulted in the same degree of cholestasis as BDL regarding bilirubin, AST
and AP serum levels. Thereafter, bilirubin, AST and AP serum levels remained elevated in the BDL group,
while these parameters returned to normal values within 14 days in the pBDL group. Necrosis formation
peaked 3 days after BDL, and was significantly lower after p-BDL (16% vs 5%, p=0.001). Consequently,
Ki-67 expression on day 5 was significantly higher after BDL than after pBDL (20 vs 3.9 cells/high power
field, p= 0.01). Also, biliary pressure was significantly higher 3 days after BDL than after pBDL (10.7 vs
5.3mmHg, p=0.02). In the second week after surgery, neither pBDL nor BDL revealed siginifcant amounts
of necrosis or cellular proliferation.
Conclusion: Cholestatic liver injury in mice is biphasic. The partial bile duct ligation model represents a
model of spontaneous reversal of cholestasis. Although pBDL results in the same degree of cholestasis
regarding serum parameters, biliary necrosis with consequent liver regeneration are drastically reduced.
Biliary necrosis are due to the increase in biliary pressure after bile duct occlusion.
43.4
Deletion of cd39 on natural killer cells attenuates warm partial hepatic ischemia/reperfusion injury
G. Beldi1, Y. Banz2, A. Kroemer2, A. Pexa2, Y. Wu2, X. Li2, S. Robson2 (1Bern, 2Boston/US)
Objective: CD39 (nucleoside triphosphate diphosphohydrolase (NTPDase)-1) is an ecto-nucleotidase
that is expressed by the vasculature and defined immune cell subsets that are involved in the early phase of ischemia reperfusion injury (IRI) e.g. natural killer NK and NKT cells. CD39 generates adenosine
when in tandem with CD73 to modulate purinergic signaling by such cells. Pharmacological agonists
for the adenosine-2A receptor provide protection against warm partial liver IRI, putatively in an NKT cell
generated interferon-gamma (IFN gamma) dependent manner. However, the effects of CD39 alone and
changes in local pericellular nucleotide hydrolysis during hepatic IRI upon the specific roles of NK cells
and the contributions to IFN gamma production are unknown.
Methods: Secretion of IFN gamma and cytotoxic activity were assessed in purified mouse NK cells. Liver
injury was evaluated in a model of partial warm ischemia in wild type and mutant mice null for CD39.
Adoptive transfers were performed in Rag2/common gamma null mice (deficient in T cells, B cells and
NK cells) using NK cells of wild type mice and mice with targeted deletion of either CD39 or IFN gamma.
Results: CD39 is the dominant ectonucleotidase in NK cells as these cells lack expression of CD73/ecto5’-nucleotidase, unlike NKT cells that express both. Hepatic NK cells are consistently increased in number
in mice null for CD39 when compared to wild type controls. The CD11bhiCD27low subset of NK cells
(less aggressive, long-lived) account for these relative increases. Deletion of CD39 further also results in
aberrant cell responses in vitro with decreased secretion of IFN gamma in response to exogenous IL-12
and IL-18. Furthermore, secretion of IFN gamma is largely abrogated in response to additional ATPyS (a
non-hydrolysable ATP analog) in CD39 null relative to wild type NK cells. Cytotoxic activity of NK cells
was significantly decreased by incubation with non- hydrolysable ATPyS in vitro. Somewhat paradoxically,
CD39 null mice show protection against the early liver injury seen with warm partial hepatic IRI in wild
type mice. Adoptive transfer of CD39 null or wild type NK cells confirms the protective effect of CD39 deletion in these specific innate immune cells. IRI was also attenuated in IFN gamma null mice; improvements
in IRI seen with adoptive transfer of IFN gamma null NK cells into Rag2/common gamma null mice were
comparable to that seen with CD39 null NK cells.
Conclusion: CD39 deletion modulates NK numbers in mutant mice and their function both in vivo and
in vitro. Disordered purinergic signaling in this setting of CD39 deletion results in defects in IFN gamma
secretion by NK cells that limit injury post hepatic ischemia and reperfusion.
43.5
Tolerance induction to xenogeneic islets by anti-CD 154 mab and rapamycin is based on anergy and
regulation
Y. Muller1, G. Mai1, Ph. Morel1, C. Gonelle1, V. Serre-Beinier1, G. Puga Yung1, J. Seebach1, T. Wekerle2, L.H.
Bühler1 (1Genève, 2Wien/AT)
Objective: Combined treatment with anti-CD154 monoclonal antibody (mAb) (MR1 hamster anti-mouse
CD154 mAb) and rapamycin (RAPA) was previously shown to induce indefinite survival of concordant
rat-to-mouse islet xenografts. The aim of the present study was to investigate whether classical anergy
and/or regulation by IL2-dependent CD25+ regulatory T cells played a role in the induction and maintenance of the observed tolerance.
Methods: Diabetic C57/BL6 mice were transplanted with rat islets under the kidney capsule. The following
treatment groups were performed: Group 1) control group, i.e. islet transplantation (Tx) without further
therapy; Group 2) RAPA group, 0.2 mg/kg, from days 0 to 14; Group 3) MR1 group, 0.5 mg i.p on days
0, 2 and 4; Group 4) combination therapy of MR1 and RAPA; in addition recombinant IL2, a neutralizing
anti-IL2 mAb or a depleting anti-CD25 mAb was administrated either early (0-28d) or late (100- 128d)
post-Tx to the combination therapy. Islet function was determined regularly by glycemia and histology on
day 200 and at time of rejection. Levels of T regulatory cells in the blood were measured over time by flow
cytometry analysing the proportion of Foxp3+ CD25+ in the CD4+ lymphocyte population.
Results: Exogenous IL2, anti-IL2 mAb or anti-CD25 mAb induced rejection when administered early together with MR1 and RAPA. In contrast, when IL2, anti-IL2 mAb or anti-CD25 mAb were given late, the majority of xenograft recipients remained tolerant. The proportion of Foxp3+ CD25+ Tregs in blood showed a
significant decrease when anti-CD25 mAb was given, whereas Tregs level in mice treated with RAPA and
MR1 alone doubled during the first 20d after transplantation.
Conclusion: Tolerance induction by RAPA and MR1 treatment for islet xenografts was reversed by administration of exogenous IL2, anti-IL2 mAb or anti-CD25 mAb at the time of transplantation, suggesting
classical anergy and regulation by IL2-dependent CD25+ Delayed administration of IL2 or anti-IL2 mAb
or anti-CD25 mAb did not abrogate tolerance in the majority of recipients, indicating that maintenance
of tolerance became less dependent on anergy and regulation over time. CD25+ T regulatory cells play
therefore a critical role in the early time of a xenotransplantation.
43.6
IL-17 favours expansion of IL-17 producing CD4+ T cells through monocyte activation.
X.S. Huber, C. Feder-Mengus, D.M. Frey, T. Fahnenstich, M. Heberer, G. Spagnoli, G. Iezzi (Basel)
Objective: IL-17 producing CD4+ T cells, also termed Th17, have been recognized as key players of several autoimmune and inflammatory diseases, including inflammatory bowel disease and in transplant
rejection. On the other hand, their potential role in protective immune responses, in particular against
self tumor-associated antigens, is currently under investigation. The nature of the stimuli governing the
differentiation and expansion of human Th17 is poorly understood. Moreover, mechanisms underlying
the inflammatory effect of IL-17 remain to be completely clarified. We analysed IL-17 receptor (IL-17R)
expression on human peripheral blood mononuclear cells (PBMC) and evaluated the effects of their exposure to IL-17.
Methods: IL-17R expression on human PBMC was tested by flow cytometry. CD14+ monocytes isolated
by magnetic beads were stimulated with recombinant IL-17 and or lipopolysaccharide (LPS) and expression of surface markers, and cytokine genes or cytokine secretion was evaluated by flow-cytometry, quantitative real-time PCR and ELISA, respectively. Monocytes exposed to IL-17 in the presence of LPS were
cultured with allogeneic CD4+ T cells and cytokine production by the expanded T cells was evaluated at
the end of the culture by intracellular cytokine staining.
Results: IL-17R was expressed on all CD14+ monocytes and on a restricted subset (<4%) of CD8+ T
cells. In contrast, CD4+ T cells e B lymphocytes did not show any significant expression. Interestingly,
dendritic cells (DC), generated upon culture of CD14+ monocytes in the presence of GM-CSF and IL-4 or
IFN-a, were also negative for IL-17R expression. Exposure of CD14+ monocytes to IL-17 did not induce any
significant change in the basal or LPS-induced expression of HLA-class I, class II, CD80, CD83 or CD86
molecules. However, when cytokine production was evaluated, the amount of IL-1b and IL-23 (but not of
IL-12p70) released by monocytes upon LPS and IL-17 stimulation, was significantly higher (up to 4 fold)
than the one from monocytes stimulated with LPS only. This effect was abrogated by the addition to the
culture of an IL-17R-specific antibody. Finally, when cultured with allogeneic memory CD4+ T cells, LPS/IL17-treated monocytes led to the expansion of significantly higher fractions of Th17 cells than monocytes
exposed to LPS alone (19±0.19 vs. 12.2±0.87, p=0.003).
Conclusion: Our data indicate that IL-17 acts on peripheral blood monocytes by boosting LPS-initiated IL1b and IL-23 secretion, thus favouring the expansion of Th17 cells. The interaction IL-17-monocytes might
represent a target for therapeutic intervention in inflammatory bowel disease and transplant rejection or,
alternatively, for the induction of immune responses against tumor associated antigens.
43.7
Intra-pulmonary CD26/DPP IV enzymatic activity: from organpreservation to immunosuppression
W. Jungraithmayr1, B. Oberreiter1, I. De Meester2, P. Vogt1, W. Zhai1, M. Cardell1, K. Augustyns2, S. Hillinger1,
S. Arni1, S. Scharpe2, W. Weder1, S. Korom1 (1Zürich, 2Antwerpen/BE)
Objective: Inhibiting rat intra-pulmonary CD26/DPP IV enzymatic activity strikingly ameliorated early graft
ischemia/reperfusion (I/R) injury after extended ischemia. In a second model, systemic administration
of a catalytic activity inhibitor following orthotopic lung allo-transplantation (Tx) abrogated acute rejection
and preserved pulmonary function. In this study, we analyze whether organ-specific CD26/DPP IV-enzymatic-activity-inhibition within a lung allograft will modulate the host immune response toward the transplant over an extended period of time in the presence of standardized immunosuppression (cyclosporine
A, CsA).
Methods: Lewis (LEW) rats received LBNF1 (LEWxBN) left orthotopic pulmonary transplants (n=4-5/
group). Donor lungs in group I were flushed with Perfadex®, whereas grafts in group II were perfused
with Perfadex®+25µmol/L AB192 (bis(4-acetamidophenyl) 1-(S)-prolylpyrrolidine-2(R,S)-phosphonate).
After Tx, recipients were treated with 2.5mg CsA/kg/d. The grafts of both groups were harvested at day
5 post Tx and assayed for oxygenation capacity and evaluated for histopathological signs of rejection
(ISHLT-International Society of Heart and Lung rejection grading). In addition, proliferating cell nuclear
antigen (PCNA) staining for rejection-associated cellular infiltrates was performed.
Results: At day 5 post Tx, pulmonary function was significantly superior in group-II- vs. group-I-grafts: pO2
was 109±33 vs. 53±19mmHg (p<0.05). Histopathologically, group-II-transplants showed only minimal/
mild signs of rejection, vs. moderate/severe rejection in group I (ISHLT A: 1.6±0.5 vs. 3.6±0.6). PCNA
staining indicated a significant (p<0.01) decrease in rejection-associated perivascular (36.1±15.2 vs.
2.1±1.7) and peribronchial (34.7±6.9 vs. 11.3±3.7) positivity from group-I to group-II-grafts, respectively.
Conclusion: Preconditioning of the allograft by organ-specific CD26/DPP IV enzymatic activity inhibition
strikingly ameliorated the host acute rejection pathway. Even in grafts exposed to short ischemic time, and
in the presence of standardized immunosuppressive therapy, singular neutralization of catalytic activity
induced a lasting immunomodulatory effect. Further studies are warranted to decipher the interaction
between organ-specific CD26/DPP IV enzymatic activity and the systemic immune response toward
allo-Ag.
43.8
Human mesenchymal stem cells express albumin in vitro, engraft but do not differentiate into hepatocytes in mice with liver injury
R.M. Baertschiger, M. Peyrou, Ph. Morel, A. Kaelin, A. Sgroi, V. Serre-Beinier, L.H. Bühler, C. Gonelle-Gispert
(Genève)
Objective: Introduction: Adult human multipotent mesenchymal stromal cells (MSC) obtained from bone
marrow can be differentiated into mesenchymal lineages, like adipocytes, chondrocytes and osteoblasts.
Their differentiation toward endodermal lineages, like hepatocytes, has been described in vitro but remains a subject of debate. Our aim was to isolate and characterize MSC from pediatric and adult donors
and to investigate their potential to differentiate into hepatocytes in vitro and in vivo, in mice in which liver
regeneration was induced by partial hepatectomy (PHx).
Methods: We isolated MSC from adult (aMSC) and pediatric (pMSC) human bone marrow (n=44). After density gradient purification mononuclear cells were cultured in expansion medium. Expanded cells
were characterized by flow cytometry and their ability to differentiate into adipocytes and chondrocytes
was assessed. To induce hepatocyte differentiation in vitro, MSC were co-cultured for 4 weeks with huH7
cells (human hepatocyte cell line) using a transwell system and a medium containing HGF, FGF4 and
oncostatin M. Expression of hepatic markers like a-feto-protein and albumin was analyzed by RT-PCR. To
investigate contribution of MSC to liver regeneration, MSC were transplanted either into the spleen or into
the liver parenchyma of NOD/SCID mice two days after PHx (35-70 %). To prevent endogenous liver re-
53
generation one group was treated with retrorsine. Liver and spleen were harvested at various time-points
and analyzed for engraftment and differentiation by immunohistochemistry using specific anti-human
vimentin and anti-human albumin antibodies.
Results: Cells from pediatric and adult donors were expanded up to 19 ± 4 population doublings. Both
expressed characteristic surface markers for MSC and were able to differentiate into adipocytes and
chondrocytes. In vitro, albumin expression was detected in aMSC (2 out of 10 experiments) and pMSC (5
out of 6 experiments) after co-culture of MSC with huH7 cells. In vivo, after intrasplenic injection, MSC were
detected in the spleen up to 9 weeks after injection and in the liver only up to 11 days. Cells directly injected
into the liver parenchyma were detected up to 8 weeks. Efficiency of engraftment was similar for pMSC
and aMSC independently of retrorsine treatment. Long-term engrafted cells maintained mesenchymal
morphology and were negative for albumin.
Conclusion: Direct injection of human MSC into liver parenchyma of NOD/SCID mice allows long-term
survival of MSC without differentiation into hepatocytes. Despite more frequent albumin induction in pMSC
in vitro, they did not differentiate into hepatocytes in vivo.
43.9
Simple and effective machine perfusion of non heart beating donor pig livers before transplantation
O. de Rougemont, P. Dutkowski, K. Furrer, R. Graf, P.-A. Clavien (Zürich)
Objective: Despite its proven biochemical benefit, machine liver perfusion is not yet considered clinically
applicable due to its low practicability. We suggest a fast and feasible perfusion method to prevent injury
in non heart beating pig liver grafts.
Methods: Pig livers from a slaughterhouse (1000-1500 g each) were harvested 15 minutes after exsanguination and exposed to additional 1hr warm ex situ ischemia (30°C) followed by 7hr cold storage
(Celsior)(n=8). Another group underwent the same type of ischemia with the exception of 1hr hypothermic oxygenated perfusion (HOPE) through the portal vein during the last hour of cold preservation (n=8).
All pig liver grafts were reperfused through portal vein and hepatic artery on an isolated pig liver perfusion
system for 3hrs at 39°C with diluted pig blood (HK10.4±2.3). Pig livers without additional warm ischemia
served as controls (n=8).
Results: In controls, AST release during reperfusion remained low (2.50±0.9U/g liver) and bile flow stayed
in physiological range (8.1±0.2ml/hr). Histology showed normal sinusoidal endothelial cells and hepatocytes. In contrast, livers from NHBDs (60 min warm ex situ ischemia + 7hr cold storage) displayed diffuse
and patchy necrosis of hepatocytes, high expression of von Willebrandt Factor, ICAM-1, and a significant
increase in AST release (4.39±1.9U/g liver). Glutathione and ATP were significantly depleted. Livers treated with HOPE showed statistically significant reduction of necrosis, less expression of von Willebrandt
Factor, ICAM-1, less AST release (1.92±0.7U/g) and recovered ATP and glutathione during reperfusion.
Importantly, we could not observe sinusoidal endothelial cell injury after treatment.
Conclusion: The results demonstrate effective prevention of injury by an easily applicable approach of
endischemic 1 hour cold machine perfusion in a relevant model of NHBDs. HOPE appears as a new and
simple tool for optimizing NHBD livers.
study time, of whom 39 required reintervention within 30 days after surgery because of early vein graft
failure. Graft failure was identified with routine duplex ultrasound control before discharge of the patient.
Results: Of the 39 grafts who underwent bypass revision within 30 days after surgery 27 patients (69%)
were men and 12 patients (31%) were women with a mean age of 71.2 years. The initial operation was
performed in 10 patients (27%) for claudication, whereas 29 procedures (63%) were performed for critical ischaemia. 15 patients (38.6%) were diabetic. The site of the distal anastomosis was tibial or pedal in
23 patients (59%) and below knee popliteal in 16 patients (41%). The mean follow up was 28.5 months
(± SD 30 months). The four year patency rate was 58.5% (SE +/- 9.73%) according to life table analysis.
Primary assisted patency rate off all bypasses after 4 years was 82% (SE +/- 2.1%).
Conclusion: Early revision after infrainguinal vein bypass to the infragenicular arteries is effective and
shows an acceptable patency four years after surgery, which is significantly lower as patency of non
revised grafts.
44.3
Risk factors for wound complications after lower limb amputation in vascular surgery patients: a pilot
study
R.A. Droeser, E. Cereghetti, T. Wolff, P. Schütz, L. Gürke (Basel)
Objective: Postoperative wound complications including surgical site infections and wound dehiscence
are a common problem in patients after vascular surgery. The aim of this study was to analyze risk factors
in a cohort of patients undergoing limb amputation.
Methods: We retrospectively analysed 96 consecutive patients who underwent lower limb amputation
between January 2001 and December 2006 at the University Hospital in Basel. We excluded 6 patients
who died within 72 hours and 30 patients with traumatic amputation. To evaluate differences between
groups the Mann-Whitney U test for not normally distributed variables and Chi-square test for categorical
variables were used, as appropriate. To compare the prognostic value of individual parameters, odds
ratios (OR) were calculated in a logistic regression model. A p-value <0.05 was considered statistically
significant. All calculations were performed using Stata 9.2.
Results: Fifteen of the 60 patients (25%) had a postoperative wound complication. Baseline characteristics of patients with and without postoperative wound complication were not different in terms of gender,
body mass index, ASA-score, stage of peripheral arterial disease, smoking history and pre- and postoperative haemoglobin concentration. Patients with complication had a higher median age (79 [IQR 72-84]
vs 73 [IQR 67-78], p=0.04) and had more often trough knee amputation (75% vs.21%, p=0.02). In a
univariate logistic analysis, age (OR=1.07, p=0.068), elevated blood glucose (OR=2.8, p=0.071), steroid
therapy (OR=2.9, p=0.156), trough knee amputation (OR=11, p=0.046) and blood transfusion (OR=2.5,
p=0.128) were the best predictors of postoperative wound complications.
Conclusion: This pilot study found that not only traditional risk factors such as age, steroid therapy and
elevated blood glucose, but also the operation technique and blood transfusion tended to increase the risk
for postoperative wound complications in patients undergoing lower limb amputation. This data should
be confirmed in larger studies.
44.4
Vascular Surgery
44
44.1
Limb salvage: when arm veins come to legs’ assistance in patients with critical ischemia
F. Vauclair, F. Saucy, J. Corpataux, C. Haller (Lausanne)
Objective: Evaluation of long term patency of arm veins used as best autogenous graft remaining for
lower extremity revascularization.
Methods: Between 2001 and 2006, we recorded prospectively a consecutive serie of 69 infrainguinal
bypass in 64 patients using arm veins as best conduit available for lower limb revascularization. Infrainguinal bypass were stratified by localization as above or below the knee and characteristic of graft as
single vein or composite and were correlated with primary, primary assisted and secondary patency.
Statistical methods included life-table analysis and ANOVA.
Results: The overall primary patency of by-pass at 36 months was 69.6% (above knee: 83.3%, below
knee: 64.1%, distal: 64.4%). Overall primary assisted patency was 83.3% ( above knee: 89.5%, beolw
knee: 87.2%, distal: 78.8%), and the overall secondary patency was 91.8% ( above knee: 98.2%, below
knee: 94.9%, distal: 91.8%).
Conclusion: Arm veins as best autogenous graft remaining for lower extremity revascularization have a
good permeability and a low complication rate. We recommend to use it before prosthetic graft.
44.2
Long-term results after graft revision in infrainguinal vein bypass to the infragenicular arteries
S. Reck1, L. Gürke1, T. Wolff1, P. Stierli2, T. Eugster1 (1Basel, 2Aarau)
Objective: Bypass with autologous vein is a well established treatment for infrainguinal revascularisation.
Long-term outcome of vein graft in terms of patency is superior to the use of synthetic graft material.
However, early vein graft failure is a significant problem. Furthermore patency between revised graft and
non-revised grafts are discussed controversial. The aim of this prospective observational study was to
investigate long-term patency of autologous vein bypasses after early revision
Methods: In our prospective compiled database all infrainguinal revascularisation with autolgous vein
material performed between October 1988 and December 2006 at the University Centre for Vascular Surgery Aarau and Basel are consecutively recorded. A total of 810 reconstructions were performed during
54
Operative therapy of symptomatic functional popliteal entrapment syndrome: an exceptional case with
three recurrences
H. Kim1, R. Bühlmann1, L. Gürke2, P. Stierli2 (1Aarau, 2Basel)
Objective: The Popliteal Entrapment Syndrome (PES) describes a developmental abnormability in the
popliteal fossa with compression of the popliteal artery due to an abnormal anatomic structure (Type I-V).
This results in severe long-term damage to the artery, thus requiring early operative therapy. By contrast, in
functional PES (Type VI) the compression of the popliteal neurovascular bundle happens without anatomic abnormality and long-term damage is uncommon. Up to 77% of the normal population can provoke
a compression of the popliteal artery during active plantar flexion, but only very few have symptoms and
eventually need operation. The appropriate treatment for symptomatic functional PES is still challenging
and mandatory, which we illustrate with our case with three recurrences.
Methods: Case report A healthy 48 years old woman suffered from severe claudication on the left leg.
Duplex scanning and angiography confirmed PES. The following dorsal revision revealed no pathology.
Symptoms recurred _ year later and an orthotop, popliteo-popliteal saphenous vein interponat was done
from medial. 1_ years later symptoms slowly recurred and got so disabling, that after further 1_ years
we conducted a radical medial release operation with myotomy of the medial head of the gastrocnemius muscle combined with Turnispeed’s operation (see below). Nevertheless symptoms recurred and
14 month later we freed the vein interponat from intense scar tissue and resected the whole head of the
medial gastrocnemius muscle. Now, 3 months later, she is free of symptoms.
Results: Discussion Symptomatic functional PES is a very rare clinical condition. So far two different
operative techniques have been described. Levien suggests the resection of 1 cm of the entire muscular
portion of the medial head of the gastrocnemius muscle, called “surgical myotomy alone”. Turnispeed favourites the resection of the plantaris muscle, release of the medial tibial attachment of the soleus muscle,
excision of the anterior fascia of the soleus muscle and the posterior fascia of the popliteus muscle, as he
postulates the neurovascular compression at the level of the soleal sling being an important factor for the
symptoms. Recurrences are said to occur in up to 36%. Speaking of recurrences, differential diagnosis
as the chronic compartment syndrome, the medial tibial syndrome and orthopaedic disorders have to be
ruled out. In our case, the patient experienced symptom free intervals after every operation. But even after
the third operation, where we combined the techniques of Levien and Turnispeed, the symptoms recurred.
Having finally resected the whole medial head of the gastrocnemius muscle and the intense scar tissue
in the last operation, we hope having treated the patient definitively.
Conclusion: Treating symptomatic functional PES, we recommend primarily a radical operation combining the techniques of Levien and Turnispeed. In rare cases, a complete resection of the medial head of
the gastrocnemius may be necessary.
44.5
51
Emergency EVAR or open repair or RCTs for RAAA? – A thorough analysis after 10 years of eEVAR at
Zürich University Hospital
D. Mayer, T. Pfammatter, M. Genoni, M. Lachat (Zürich)
Vascular Surgery
Objective: Emergency EVAR for RAAA, although widely adopted, is still discussed controversially and
some authors demand for RCTs to compare endovascular repair (ER) with open repair (OR) in these
patients.
Methods: 1. 10 year analysis of RAAA treatment (ER and OR) at Zurich University Hospital. 2. Literature
Review for contemporary comparative studies including RCTs (ER vs OR).
Results: ZUH analysis: From 1998 to 2007, 107 (53%) RAAA have been treated by OR and 95 (47%) by
ER (n=202, intention-to-treat protocol since 2000, unstable patients not excluded from ER). 30d mortality
rate is 33% for OR and 11% for ER (RRR 66%, ARR 22%, NNT 4.5). Literature review: Of 22 comparative
studies of ER vs OR (including 1 RCT and 2 database analysis) not a single study showed worse results
with ER than with OR. There was a clear trend towards a better short-term outcome for ER (calculated
mean 30d mortality 25%) than for OR (calculated mean 30d mortality 42%). However, lack of reporting
standards circumvent firm statistical conclusions.
Conclusion: Emergency EVAR provides excellent short-term results even in an intention-to-treat setting
with inclusion of unstable patients. This is widely confirmed in the contemporary literature of 22 comparative studies including one RCT and two large database analysis. Unfortunately, due to a lack of reporting
and treatment standards, these results cannot be turned into firm evidence and some authors advocate
for RCT. However, for many groups including ours with comparable low short-term mortality with ER compared to OR, an ethical dilemma is created whether they can offer OR (with potential worse outcome) to
a patient suitable for ER.
A new rodent model for controlled in-vivo reperfusion after severe acute hind limb ischemia
F. Dick, J. Li, M. Giraud-Flück, C. Kalka, J. Schmidli, H. Tevaearai (Bern)
44.6
Thoraco-abdominal-aneurysm surgery: rapid conversion of partialto full CPB via a threefold self-expanding cannula setup
C. Huber, B. Marty, P. Tozzi, D. Delay, E. Ferrari, P. Ruchat, J. Horisberger, L.K. von Segesser (Lausanne)
Objective: Evaluate impact and feasibility of rapid conversion from partial cardiopulmonary bypass (CPB)
with active cooling and low systemic heparinization to full flow support by a threefold self-expanding cannula setup to allow for dual arterial perfusion and adequate peripheral venous drainage during open
repair of thoraco-abdoninal-aortic aneurysms.
Methods: The last 11pt of 147 consecutive patients undergoing open surgical repair of thoracic or thoraco-abdominal aortic aneurysms with partial CPB (50% flow), active cooling (29°C) and low systemic
heparinization were equipped with a threefold cannula setup to allow for rapid conversion to full CPB.
Four patients (36%) underwent thoracic aneurysm and 7pt (64%) thoraco-abdominal-aortic aneurysm
surgery. Eight pt (73%) presented with isolated aneurismal morphology and 8pt presented a concomitant dissection. The threefold cannula setup includes a femoral 18F/36F self-expanding venous cannula
(lengths: male 630mm/ female 530mm) (Smartcanula), a 12F/24F self-expanding arterial cannula
(Smartcanula) and an 18F Biomedical cannula (Medtronic). All three cannulas are linked via a W constructed from three Y connectors.
Results: Three of 11pts (56±13y 5m/6f) required rapid conversion to full CPB. In 2pt for arch involvement
and in 1 pt because of aortic rupture. Flow increase from 50% (2.1±0.2 l/min) to targeted femoro-femoral
flow of 3.9±0.4 l/min (weight 68±12 kg / BSA 1.74±9.17 m2) was achieved by gravity drainage alone. A
further increase to 105% or 4.1±0.5 l/min flow could be generated with the current setup. In one patient
supra-aortic perfusion after clamping became necessary because of ventricular fibrillation. Dual arterial
cannulation was achieved via a transapical access with the additional 18F Biomedicus cannula. Neither
of the 11patient experienced renal insufficiency requiring dialysis or paraparesis and paraplegia. No patient was taken back to the OR for hemorrhage control. Hospital mortality was 9%.
Conclusion: The threefold self-expanding cannula setup for open repair of descending thoracic aortic
aneurysms appears to be an elegant approach allowing proximal unloading and distal protection with
moderate hypothermia and low systemic heparinization. This setup further harbors the potential for full
CPB with or without dual arterial cannulation and for deep hypothermia and circulatory arrest.
44.7
Prevention of rupture of abdominal aortic aneurysm
H. Savolainen (Bern)
Objective: Two thirds of patients with an abdominal aortic aneurysm (AAA) have relevant coronary artery
disease (CAD). AAAs are prevalent in up to 16% of patients with CAD. Screening of AAA in the general
population is controversial, but may be cost-effective in certain selected patient groups. Aim was to assess the potential of finding AAA prior to rupture among patients with known CAD. Main endpoint was
whether AAA could have been found during regular follow-up of CAD by sonography or at other time of
cardiac evaluation.
Methods: Retrospective study, tertiary referral center. 213 consecutive, formerly unknown rAAAs, treated
emergently for symptoms (n = 91) or rupture (n = 122) (rAAA) between January 1998 and June 2005.
Patient charts were analysed to determine whether CAD had been diagnosed prior to AAA emergency.
Cardiovascular risk factors and history were assessed.
Results: At emergency presentation, patients had a mean age of 71 (+/-9) years, twenty (9%) were
female. AAA had a mean diameter of 7.6 cm. Two thirds (143) were clinically obese with mean body
mass index (BMI) 27 (+/-5). 137 (64%) were active smokers, 32 (15%) had diabetes, 151 (71%) were
hypertensive, and 80 (38%) received statin treatment. CAD had been diagnosed in 95 (45%) patients 9
years earlier. Thirty-five (16%) had had myocardial infarction. Echocardiography had been performed in
52 (24%). Thirty day mortality after open surgery was 25 (21%).
Conclusion: A high percentage of patients presenting with rAAA have been under dedicated cardiologic
care for some time. Earlier screening could have prevented AAA rupture. All patients undergoing evaluation for CAD should be examined by abdominal sonography to detect AAA.
51.1
Objective: Reperfusion injury accounts for a considerable part of tissue loss after acute extremity ischemia. Controlled oxygen-free reperfusion before reversal of ischemia may alleviate reperfusion injury. We
looked for an adequate rodent model of severe acute limb ischemia (SALI) in which controlled and isolated in-vivo reperfusion can be studied.
Methods: Wistar rats were subjected to controlled tourniquet ischemia of one hind limb for 4 hours. Tourniquets were placed around the proximal thigh and conducted underneath the femoral neurovascular
bundle through a short skin incision in the groin. Arterial limb ischemia was completed by temporary
ligation of the arterial axis, whereas - importantly - venous outflow was preserved. Ischemic damage was
assessed in two groups: in a conventional group (n=7), tourniquet and arterial ligatures were released
after 4 hours to re-establish normothermic blood circulation. In a controlled reperfusion group (n=7), the
epigastric artery was catheterized in order to first perfuse the limb with cooled heparine solution (15°, 20
minutes) after central clamping and incision of the femoral vein (sequestered blood was thereby washed
out). Blood circulation was re-established thereafter. All rats were sacrificed after 4 hours of blood reperfusion. Non-ischemic limbs were used as controls in both groups. Investigated parameters included limb
circulation (assessed by laser Doppler), tissue edema (wet-to-dry ratio), muscle viability (MTT assay), and
muscle contractility (ex-vivo standardized electrical stimulation).
Results: All ischemic limbs from both groups demonstrated significant edema formation (159+/-44%,
P<.001), as well as a significantly reduced muscle viability (65+/-13%, P<.001) and contractility (45+/34%, P=.003) as compared to contra-lateral non-ischemic limbs (100%). However, controlled initial reperfusion with heparine led to significantly less edema (132+/-16% vs 185+/-42%, P=.011) and preserved muscle viability (74+/-11% vs 57+/-9%, P=.004) and contractility (68+/-40% vs 26+/-7%, P=.045)
significantly better as compared to simple re-establishment of blood circulation. In addition, level of limb
circulation was normalized after controlled reperfusion in contrast to simple release of tourniquet (97+/17% vs 79+/-20%, P=.027).
Conclusion: This tourniquet limb ischemia model is a reliable and effective way to induce SALI in rats. The
arterial access via epigastric catheterization allows for in-vivo assessment of isolated controlled reperfusion before release of tourniquet. Reperfusion injury after SALI seems to be alleviated by initial reperfusion
with oxygen-free and cooled heparine solution.
51.2
Microscopic aspects of the ascending aorta in 38 patients treated at the Inselspital Bern
J. Janzen1, I. Schwegler2, J. Schmidli2 (1Gümligen, 2Bern)
Objective: A pilot study with 38 operative specimens obtained from the ascending aorta were performed.
The purpose was to clarify the underlying causes of its aortic diseases.
Methods: Surgical probes from 21 ascending aortic aneurysms, 16 type A-dissections and one false aneurysm were provided. Specimens were embedded in paraffin blocks. Each histological section, between
5 to 7 micrometers in thickness, was stained with Hematoxylin & Eosin, Elastica-van-Gieson and Orcein.
For statistical analysis Stary`s and Schlatmann-Becker`s classifications were used.
Results: Microscopic aspects were inhomogeneous: 10 cases presented atherosclerotic lesions, 25
cases had a disease of the media and 3 cases pathologic changes in the adventitia. Surprisingly, in 36
cases alterations of vasa vasorum in the media and adventitia were seen.
Conclusion: We assume that vasa vasorum play an important role in the etiology of diseases in the ascending aorta.
51.3
Protheto-ureterale Fistel nach Aortenprothesenimplantation
P. Füglistaler, R. Shayesteh, M.K. Schilling, D. Kreissler-Haag (Homburg-Saar/DE)
Objective: Spätinfektionen nach Aortenprothesenimplantation verlaufen oft latent; nur selten tritt eine lebensbedrohliche Hämorrhagie auf. Wir berichten über 2 Patienten mit einer sehr seltenen protheto-ureteralen Fistel bei Spätinfektion einer Aortenprothese.
Methods: Retrospektive Analyse aller Aortenprotheseninfektionen über die letzten 5 Jahre.
Results: Bei 2 weiblichen Patienten im Alter von 48 bzw. 56 Jahren kam es 8 bzw. 11 Jahre nach Implantation einer Aorto-bifemoralen bzw. Aorto-biiliacaler Prothese zu einer Hb-relevanten Makrohämaturie. Die
rasch eingeleitete Diagnostik führte bei einer Patientin initial zu einer Nephrektomie wegen fälschlichen
Verdachts auf eine Glomerulonephritis. Schliesslich erfolgte bei beiden Patienten eine operative Revision
mit Aortenprothesenausbau, Abstrichentnahme, Débridement und Spülen des Prothesenlagers sowie
anschliessender Implantation einer Silberprothese, Bildung einer Netzplombe zur Deckung der neuen
Prothese und Übernähung der Ureterperforationsstelle. Regelmässige Nachkontrollen über 3 bzw. 5 Jahre bei den beiden Patienten ergaben bis anhin keinen Hinweis auf Re-Infekt der Prothese.
Conclusion: Nach Aortenprothesenimplantation muss die Kombination von Fieber und Makrohämaturie
differentialdiagnostisch an eine Infektion der Aortenprothese denken lassen. Die Hämorrhagie erfordert
die notfallmässige Indikation zur Blutstillung sowie Infektsanierung durch Prothesenwechsel.
55
51.4
Short-term outcome after implantation of bovine pericardial vascular prosthesis in infectious situations
C. Rouden, T. Eugster, T. Wolff, P. Stierli, L. Gürke (Basel)
Visceral Surgery
Objective: Shelhigh NoReact® Pericardial Prostheses (SHP) may offer a new alternative to cryopreserved
homografts for peripheral artery surgery in infectious situations. The Shelhigh NoReact® is made of glutaraldehyde cross-linked bovine pericardium, detoxified and heparin rinsed. Tissue Detoxification should
have a better resistance against infection and calcification than a prosthetic graft. Moreover SHP is more
easily available than a homograft. We report on our first experience of patients treated with SHP.
Methods: We retrospectively evaluated all patients treated by SHP implantation at Basel University Hospital. Main outcome measures were intraoperative and postoperative mortality and complications directly
linked to surgery.
Results: The study population consisted of 7 SHP implantation procedures in 5 male patients with a median age of 48 years (range 41- 81) between December 2006 and December 2007 (12 months). Median
follow-up was 4 months (range 1-12 months). We used 2 bifurcated (18/9mm and 20/10mm) and 5
monotube prostheses (6mm, 2x 8mm, 9mm and 10mm). Indications were: 1 aorto-biilical graft infection
caused by diverticulitis, 1 infected Dacron bypass caused by an inguinal abscess after coronarography,
1 acute ruptured brachial aneurysm artery in a patient with intravenous drug abuse, 1 primary aortitis of
an infrarenal aortic aneurysm with retroperitoneal abscess by bacteroides fragilis, and 1 ruptured anastomotic aneurysm after complex femoro-crural revascularisation. There was no intraoperative mortality.
However postoperative morbidity was high and reoperations were frequent. One patient died from acute
bleeding 23 days after SHP implantation during re-operation because of persisting abdominal infection.
One patient had to be re-operated several times for debridement of infectious tissue, leading eventually
to complete healing. One patient was re-operated because of partial necrosis of a skin flap. Other than
that, no complication directly associated with the SHP implantation was found, and no prosthesis had
to be removed.
Conclusion: The results reported here suggest that the use of SHP for vascular reconstruction in infectious
situations might be considered as a valid alternative in situations where autologous veins or homograft
prosthesis are not avalaible. This bioprothesis is easy to provide and appears to have a reasonable complication rate. Because of the small size of our patient series and the short follow-up period, our findings
need to be corroborated by a larger prospective study with a longer follow-up period.
52.1
51.5
Recurrence after surgery for varicosis in the groin is not dependent on body mass index
M. Bergner, W. Mouton, T. Zehnder, M. Naef, H.E. Wagner (Thun)
Objective: To investigate if the body mass index (BMI) is different between the recurrence groups (incomplete ligation also defined as technical error, neo-revascularisation, uncertain and mixed) in same site
inguinal recurrent varices after surgery (REVAS) patients.
Methods: During a six and half year time span we retrospectively analysed 203 consecutive procedures
in 153 patients undergoing same site recurrent vein surgery in the groin. BMI‘s were calculated and compared with each other within the different REVAS nature of source groups.
Results: The median BMI was 28 for patients undergoing recurrent surgery in the groin with no relevant
difference in BMI within the different nature of source groups (confidence interval for the difference of
adjusted group means equals [-1.5, 2.6]).
Conclusion: There is no relevant difference in BMI between the two most prominent REVAS groups. Of
course this may be due to small sample size, but confidence limits for difference of mean BMI indicate
that this is not very large.
51.6
Is carotid endarterectomy a trainee operation?
H. Savolainen1, B. Gahl1, H. Lutz2 (1Bern, 2Giessen/DE)
Objective: Recent dramatic changes in surgical training due to working hour regulations may lead to lack
of competence. Traditionally, carotid surgery has been the domain of specialists. The aim of our study was
to compare the outcome of carotid endarterectomy performed by vascular surgical trainees (T) versus
consultants (VS).
Methods: Retrospective study. 1379 consecutive patients underwent carotid endarterectomy (CEA) as
sole procedure either under local or general anesthesia (LA/GA) (1995-2004). All patients were admitted to intensive care unit (ICU) for 24 hours. Trainees performed 475 (34.5%), consultants 904 (65.5%)
operations.
Results: Patient characteristics with regard to preoperative neurological status were similar. Trainees
operated on 61.4% asymptomatic patients, VS on 56.8% (p=0.09). Shunt use did not differ (16% Trainee
vs. 17.8% VS). Clamping time and total operating time were longer among trainees (41.9 min vs. 33.5
min; p<0.001 and 121.2 min vs. 101.8 min; p<0.001, respectively). Postoperative stroke and death rates
(3.2% vs. 3.1% and 0.4% vs. 0.9% respectively) did not differ. Peripheral nerve complications were more
common among trainees (12.2% vs. 6.5%; p<0.0001). 95% of these nerve injuries had resolved at three
months’ follow up.
Conclusion: Carotid endarterectomy can be performed safely by a trainee vascular surgeon assisted by
a consultant.
56
52
Evolution in operative and non-operative management of hepatic trauma: a 20-year single-center experience
S. Breitenstein, H. Petrowsky, S. Räder, D. Perez, M. Keel, P.-A. Clavien, O. Trentz (Zürich)
Objective: Advances in diagnostic imaging and emergency management during the past two decades
have influenced the practice of liver trauma management. Therefore, we investigated the impact of these
factors on the outcome after hepatic trauma with special emphasis on operative- (OM) and non-operative
management (NOM) of hepatic trauma in a large consecutive single-center series over a 21-year period.
Methods: 350 consecutive patients with liver trauma treated between 1985 and 2006 at a single trauma
center were reviewed. Mechanisms of injury, diagnostic imaging, hepatic and associated injuries, management (OM vs. NOM) and outcome were evaluated. The analysis was evaluated separately for the
early (1985-1995) and late (1996-2006) study period
Results: 287 patients (82%) with blunt injury and 63 patients (18%) with penetrating liver trauma were
treated. OM (197 patients, 56%) and NOM (153 patients, 44%) were comparable regarding severity of
liver damage and associated injuries. The mortality rate was 34% for the early period and improved to
23% in the late period. While only the minority of patients was treated non-operatively during the early
period (OM 91%, NOM 9%), there was a significant shift to NOM in the later period (OM 40%, NOM 60%).
A significantly increased use of CT scan as diagnostic modality and shorter operation times (OM group)
was observed in the late study period (137 vs. 229 min, p<0.01). Age, operative therapy, transfusion
requirement, as well as associated head and pelvic injuries were significant predictors of poor outcome
Conclusion: During the last decade, there was a significant change in the management of hepatic trauma
which resulted in improved survival. Non-operative management of hepatic trauma became the treatment of choice in hemodynamically stable patients and is associated with a high success rate. For patients requiring OM, the duration of initial surgery should be kept as minimal as possible.
52.2
A randomized controlled trial on pharmacological preconditioning in liver surgery using a volatile
anesthetic
S. Breitenstein, B. Beck-Schimmer, M. Puhan, E. De Conno, W. Jochum, D. Spahn, R. Graf, P.-A. Clavien
(Zürich)
Objective: In liver surgery, ischemic preconditioning and intermittent clamping are the only established
protective strategies to reduce tissue damage due to ischemia during inflow occlusion. Preconditioning
with volatile anesthetics has provided protection against cardiac and renal ischemic injury in several animal models through NO and HO-1 pathways. But pharmacological preconditioning has never been tested
in patients undergoing liver surgery in a randomized trial. The objective of this sudy was to evaluate the
effects of pharmacological preconditioning with a volatile anesthetic in patients undergoing liver resection with inflow occlusion.
Methods: 64 patients undergoing liver surgery with inflow occlusion were randomized intraoperatively
for preconditioning with sevoflurane or not (ClinicalTrials.gov NCT00516711). Anesthesia was performed
intravenously with propofol. 30 minutes before inflow occlusion propofol was replaced by sevoflurane
in the preconditioning group. Primary endpoint was postoperative liver injury assessed by peak values
of liver transaminases. Postoperative complications were recorded according to an established scoring
system.
Results: Sevoflurane preconditioning significantly limited the postoperative increase of serum transaminase levels by 261 U/L (95% CI 65 - 458, p=0.0014) for the ALT and by 239 (95% CI -2 - 480, p=0.052)
for the AST corresponding to decreases of baseline levels of 35% and 31%, respectively. Patients with
steatosis had an even better benefit than patients without steatosis. The rates of any complication (risk
ratio 0.46, 95% CI 0.25 - 0.85, p=0.006) and of severe complications requiring invasive procedures (risk
ratio 0.25, 95% CI 0.06 - 1.08, p=0.049) were also lowered by preconditioning.
Conclusion: This first randomized trial of pharmacological preconditioning in liver surgery in humans
showed a protective effect of preconditioning with volatile anesthetics. This strategy may provide a new
and easily applicable therapeutic option to protect the liver and to lower complication rates.
52.3
Validation of the E-PASS scoring system for the prediction of mortality and morbidity in patients necessitating hepatic surgery
V. Banz, P. Studer, R. Fankhauser, D. Inderbitzin, D. Candinas (Bern)
Objective: In-hospital mortality and morbidity are, if well defined, readily measurable and objective parameters for monitoring standard of care within a single institution and for comparisons between centres.
The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was initially developed to predict
adverse postoperative effects for patients requiring elective gastrointestinal surgery ranging from laparoscopic cholecystectomy through to transthoracic esophagectomy. Our aim was to review whether the
E-PASS scoring system could be used without restrictions in hepatic surgery as a means of correctly
predicting morbidity and mortality.
Methods: E-PASS predictor equations were prospectively collected and analyzed retrospectively for 243
patients requiring hepatic resections between 2002-2006. The Comprehensive Risk Score (CRS) was
calculated using the E-PASS equations as previously stated, which includes calculation of the Pre-Operative Risk Score (PRS) and the Surgical Stress Score (SSS). Patients were divided into 5 severity groups,
also as previously stated, for whom expected adverse outcomes increase with increasing CRS. Observed
morbidity and mortality rates were compared with rates predicted by E-PASS using either the Fisher‘s
Exact Test, or for larger sample sizes the chi2 Test. The Wilcoxon rank-sum Test and the t-Test were applied
for comparison of PRS and SSS between patients with and without morbidity or mortality.
Results: The observed and predicted overall mortality rates were 3.3 and 3.7 per cent respectively, morbidity rates were 31 and 28 per cent. The E-PASS model showed no significant difference between expected
and observed in-hospital mortality (p= 0.641), indicating that it predicted outcome effectively. E-PASS
under-predicted morbidity and showed significant lack of fit (chi2= 11.1, 3d.f. p= 0.011). Although comparison of PRS and SSS between patients with and without complications revealed no overall significant
difference (t= -0.37, 241d.f. p= 0.714 and t= -1.69, 241d.f. p= 0.093), group specific comparisons showed
lack of fit for groups 1, 2 and 4. Equally, patients who died postoperatively did not have a significantly
higher PRS or SSS (p= 0.157 and p=0.305).
Conclusion: These data suggest that E-PASS does up to a certain extent accurately predict outcome in
patients undergoing hepatic resections. This was especially true for predicting mortality. Morbidity was
however under-predicted in the E-PASS model. A modified, new logistic equation might be required for
liver-specific resections in order to correctly foresee postoperative complications and mortality after hepatic surgery.
52.4
Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after
pancreatic surgery: the score needs to be adapted!
S. Deyle, M. Wagner, K. Becker, D. Inderbitzin, B. Gloor, D. Candinas (Bern)
Objective: In-hospital mortality and major morbidity following pancreatic resections has dropped significantly over the past decade. Single factors such as preoperative jaundice or renal or hepatic co-morbidity
have been found to be associated with a worse outcome in various studies. The Estimation of Physiologic
Ability and Surgical Stress (E-PASS) score was designed on the premise that the balance between the
patient‘s physiologic reserve capacity and the surgical stress may determine postoperative morbidity
and mortality. The initial calculation of the E-PASS included among 1281 patients 32 (2.4%) patients undergoing pancreaticoduodenectomy and another large study of 7146 patients incorporated only 1.77%
patients with pancreatic resections. Our aim was to review whether the E-PASS scoring system could be
used in elective pancreatic surgery as a means of correctly predicting morbidity and mortality.
Methods: Relevant data of all patients undergoing pancreatic surgery at our institution are entered in a
prospectively recorded statistical database. E-PASS data items were computed retrospectively and patients were divided into 5 severity groups for whom expected adverse outcomes increase with increasing
CRS. Operative morbidity and mortality rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS using the Mann-Whitney Test.
Results: Between January 2002 and October 2007 a total of 304 consecutive patients were operated
on pancreatic lesions. 198 patients underwent pancreatic head resections (65%), 58 distal resections
(19%), 17 total pancreatectomies (5%) and 30 other types of resection (11%). The observed and predicted overall mortality rates were 2.9% and 2.0%, mean CRS in the groups of patients who survived and
died were identical (95% C.I. of mean 0.438-0.504 and 0.219-1.19, resp.; p = 0.259). Cumulative and
predictive morbidity rates were 35% and 24%, PRS and SSS between patients with and without complications did not differ (PRS: 95% C.I. of mean 0.471-0.473 and 0.427-0.495 resp., p = 0.240; SSS: 95% C.I.
of mean 0.349-0.407 and 0.382-0.481 resp., p = 0.204). E-PASS under-predicted morbidity and showed
significant lack of fit (chi2= 11.1, 3d.f. p= 0.011).
Conclusion: The E-PASS scoring system appears to be ineffective in predicting postoperative morbidity
and mortality in patients undergoing elective pancreatic surgery. Thus, further refinements focusing on
problems specific for patients undergoing pancreatic resections may be warranted in order to delineate
differences in immediate surgical outcome.
52.5
Do different preoperative chemotherapy regimens lead to distinct complication rates after hepatic resection for colorectal liver metastasis?
P. Studer, L. Wilkens, V. Banz, D. Candinas, D. Inderbitzin (Bern)
Objective: Chemotherapy in patients with syn- or metachronous colorectal liver metastasis is an established standard therapy with a significant benefit in terms of over-all survival. Consequent alterations of
the micro- and macroscopic aspects of the liver are well-recognized and typical for oxaliplatin-based
treatments. Furthermore, in pre-treated patients an increased rate of postoperative complications after
liver resection for colorectal liver metastasis is reported. The aim of this study was to evaluate if different
preoperative chemotherapy regimens and their corresponding typical pathological changes in the liver
could influence the incidence of postoperative morbidity and mortality.
Methods: A total of 111 patients undergoing liver resection due to colorectal metastasis between 20022006 were retrospectively analysed. Patients were grouped into group A (preoperative oxaliplatin-based
chemotherapy), group B (any other preoperative chemotherapy regimens) and group C (no chemotherapy). Postoperative complications were identified according to established international standards. All liver
samples were evaluated by a blinded experienced liver pathologist with a special focus on the microscopical changes in the tumorfree liver tissue (i.e. sinusoidal occlusive syndrome, grade of steatosis,
post-chemotherapy-hepatitis). In order to rule out systematic sampling errors the prediction of individual
postoperative risk of morbidity and mortality was calculated by the E-PASS system.
Results: With 15 patients lost to follow-up, 96 liver resections were analysed. 64 patients (66.7%) received preoperative chemotherapy. Among those 42 (65.5%) belonged to group A and 22 (34.5%) to group
B. Altogether 42 (40.3%) major and minor postoperative complications were detected. The subgroup
analyses showed a complication incidence of n=19 (45%) in group A, n=9 (41%) group B, n=14 (43%)
in group C and thus no significant differences. The histopathological examinations confirmed the observations of other groups with more cases of sinusoidal dilatation in group A (78%) compared with group B
(55%) and group C (59%). All subgroups showed a higher rate of postoperative morbidity than predicted
by the E-PASS system.
Conclusion: In our series of data the frequently encountered characteristic pathological changes in livers
after chemotherapy are not correlated with the rate of postoperative complications. In this highly selected
group of patients E-PASS values underscored the rate of morbidity significantly. The high incidence of
histological changes in untreated livers bearing colorectal cancer metastases is surprising and requires
further investigations.
52.6
Patients necessitating hepatic resection for malignant or benign diseases have a similar long-term quality of life
V. Banz, R. Fankhauser, P. Studer, D. Inderbitzin, D. Candinas (Bern)
Objective: Morbidity and mortality are continuously decreasing after major hepatic surgery due to more
advanced operative methods and perioperative care. The extent and indications of liver resections (LR)
are being pushed to the limits. As survival increases post-hepatectomy, quality of life (QOL) becomes a
leading issue. Up until now, no studies address potential differences in long-term QOL in patients necessitating LR for benign or malignant conditions. Our aim was to see how postoperative diagnosis affected
long-term self estimated QOL and health.
Methods: Patients eligible for QOL analysis were selected from our prospectively collected database.
Long-term QOL was evaluated based on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30, Version 3.0) questionnaire and the liver-specific QLQ-LMC21 module with 51 questions addressing 5 functional and 3 symptom scales. EORTC scores
and clinical variables such as malignant versus benign diseases, age or extent of LR were analyzed to
identify factors influencing overall QOL. Statistical analysis included the Wilcoxon rank-sum test and a
cumulative logistic regression model.
Results: Between 2002-2006, 249 patients had hepatic surgery in our institution. Interventions were
carried out in 76% for malignant and 24% for benign conditions and ranged from segmental resections
to extended hemihepatectomies. 134 patients were contacted for further QOL analysis after a mean of
26.5 months (+/-16.2). There was no statistical difference in the global QOL and health scores between
patients with malignant and benign diseases (p=0.367) with an estimated odds ratio of 0.745 (95% CI
0.396-1.399). Note that the 95% confidence interval covers the value 1. Neither the extent of the resection
(greater 2 segments versus less than 2 segments) (p=0.975, OR 0.988, 95% CI 0.461-2.119) nor age
significantly influenced over QOL and health and (p= 0.092).
Conclusion: Contrary to general expectations, overall long-term QOL is surprisingly high in patients requiring LR for malignant diseases. Although patients with malignant conditions tended to fare worse within
certain sub-group analyses, it is reasonable to conclude that patients with malignant and benign diseases
have a similar QOL, although no p-value can be associated with this statement. A worse clinical prognosis
does not correlate with a low QOL as judged in the eyes of the patient. For selected patients, „palliative liver
resections“ may be warranted. However, we are currently monitoring extended hepatic surgery and its
associated QOL in a prospective trial with preoperative, short and long-term QOL assessment.
52.7
Is age a contraindication to pancreaticoduodenectomy?
D. Petermann, R. Ksontini, N. Halkic, N. Demartines (Lausanne)
Objective: To compare peri-operative (30 days) morbidity and mortality after cephalic pancreaticoduodenectomy in younger and older patients.
Methods: Cohort study of 98 consecutive pancreaticoduodenectomy performed for malignant or benign
diseases between January 2000 and August 2007 in a single-institution. We retrospectively analyzed
the operative data and outcomes in patients younger than 70 years and compared it with those aged
70 years or older.
Results: Out of 98 operated patients, 65 (66%) were younger than 70 years and 33 (34%) were 70 or
older (range, 35-84 years). Indications were similar in both groups and included pancreatic adenocarcinoma (43% of younger vs. 52% of older patients), chronic pancreatitis (20% vs. 0%), ampullary adenocarcinoma (17% vs. 24%), distal bile duct adenocarcinoma (3% vs. 12%) and miscellaneous indications
(17% vs. 12%). Postoperative hospital stay (23 days vs. 28 days; p=0.20), median operative time (5.4
hours vs. 5.6 hours; p=0.61) and length of stay in intensive care unit (0.8 days vs. 1.7 days; p=0.15)
were similar. Complete resection (R0) was achieved in 67% cancer in both groups. Overall morbidity
(45% vs. 52%; p=0.67) and each type of the complications (delayed gastric emptying, pancreatic fistula,
hemorrhage, intraabdominal abscess, wound infection) were also equally distributed. Total perioperative
mortality was 3%. No perioperative mortality was noticed in the younger group compared to 9% (n=3) in
the older group (p=0.036).
Conclusion: Our results confirm that duodenopancreatectomy can be performed with similar perioperative morbidity in all age groups. Mortality is low and occurs mostly in older patients. Age per se is not a
contraindication to duodenopancreatectomy.
52.8
Radiofrequency ablation (RFA) of colorectal liver metastases – a curative approach?
K. Wolff, C. Zeisel, R. Warschkow, U. Beutner, J. Lange, M. Zünd (St. Gallen)
Objective: Radiofrequency ablation (RFA) is an established procedure for the treatment of colorectal
metastases. It is mainly used for non-resectable or centrally located metastases. The procedure can be
performed percutaneously, laparoscopically or conventionally open, thus allowing its application also on
patients with limited operability. Liver resection is the primarily recommended procedure for the curative
treatment of liver metastases. The aim of this study was to investigate whether the primary radiofrequency
ablation can serve as a curative treatment and whether it has a low morbidity and mortality.
Methods: Between 1998 and 2007 68 patients (21 female, 47 male) with a median age of 61 years
(range: 35 – 87) were operated. The median operation time was 235 min (25 – 780). 90 RFAs were
preformed, of which 27 were done together with an additional liver resection (10 segment resections,
11 hemihepatectomies, 6 wedge resections). The median number of metastases treated per operation
57
was 2 (range 1 – 13); in 90% of the cases less than 5 metastases were ablated; and the total number of
lesions treated was 223. Pringle’s manoeuvre was never performed before the intervention
Results: There was no intra-operative morbidity and the post-operative mortality was 2.9% (2 patients).
The surgical morbidity was 7.8% (N=7) and the general morbidity 12.2% (11). The median overall survival
time was 43 months (95% confidence interval 24 - 61 m) after RFA alone and 59 months (95% CI: 14
– 105) after RFA with simultaneous liver resection. The 2-year disease-free survival rate was 42%. The
median size of the RFA treated metastases was 26 mm (range 10 – 70 mm).
Conclusion: RFA of liver metastases of colorectal origin is an efficient and safe procedure with an acceptable morbidity. The intra-operative use of RFA allows the destruction of non-resectable metastases
and thus can be applied as a treatment with curative intention. Further development of the RFA technology
will probably increase the possibilities for curative treatment. However, for resectable metastases the partial liver resection remains the first choice.
52.9
Impact of complications on costs in major surgery – a prospective cost analysis of 226 patients undergoing complex HPB-surgery
S. Breitenstein, R. Vonlanthen, C. Wichmann, D. Hauri, M. Puhan, P.-A. Clavien (Zürich)
Objective: Growing demand for quality in health care has triggered interest in measuring clinical outcome
and costs. Complications have become quantifiable using a severity-oriented complication score. However, no convincing data is currently available regarding the impact of complications on costs, particularly
in HPB-surgery.
Methods: Postoperative outcome and costs (calculated according to the bottom up methodology) of 226
consecutive patients undergoing major HPB-surgery in a single interdisciplinary center were prospectively analyzed over a period of two years (2005/2006). Postoperative complications were evaluated
according to a standardized severity-oriented complication score, and their impact on hospital costs was
assessed using multivariable linear regression models with costs as dependent and complication grades
as independent variables adjusted for age, Charlson Index, ASA score and nutrition risk factor, operating
time, hospital stay and malignancy of disease.
Results: 177 (75%) complex liver/bile duct operations and 55 (25%) major pancreas operations were
performed. The overall mortality rate was 3.5%, while morbidity was 59% (31% minor (Grade I/II) and
28% major complications (Grade III/IV)). Overall hospital costs per case were EUR 29’155 (quartils-range 15’436 - 32’197). Costs (EUR) increased with the degree of the most severe complication per patient,
calculated as follows: 17’263 for “no complication”, 19’063 for Grade I, 23’577 for Grade II, 42471 for
Grade III and 74’462 for Grade IV. Grad lIl and IV complications were significantly associated with costs.
Independent predictors for costs were hospital stay (>9d), operating time (>275min), and nutrition risk
score (>3).
Conclusion: This is the first in-depth cost analysis in a large HPB unit demonstrating a dramatic increase
of direct costs according to the severity of complications. Particularly major complications (Grades lll/lV)
raise the costs by up to four times per case. This data may serve to negotiate compensation from the
DRG-system particularly in centers specialized for complex HPB surgery.
53
53.2
PFN A: wissen wir nach einem Jahr mehr?
A. Missbach-Kroll, W. Nussbeck, L. Meier, R. Elke, L. Eisner (Olten)
Objective: Der PFN A wurde an unserem Spital im Dezember 2005 eingeführt. Nachdem wir letztes Jahr
unsere 3-Monatsergebnisse präsentieren konnten, liegen nun die 1 Jahreskontrollen vor. Ziel dieser Arbeit
ist es, die funktionellen und radiologischen 12 Monats-Ergebnisse der ersten 50 PFN A zu präsentieren.
Wir berichten ebenfalls über unsere Erfahrungen bezüglich Handhabung und Komplikationen.
Methods: 50 Patienten der chirurgischen und orthopädischen Klinik, welche seit Einführung des PFN A
zwischen November 2005 und Dezember 2006 mit diesem Implantat operiert wurden, konnten erfasst
werden. Es erfolgten klinische und radiologische Nachkontrollen jeweils 6 Wochen und 12 Monate postoperativ. Bei den klinischen Daten wurde vor allem auf die Mobilität anhand des Merle-dÀubigne-Scores
geachtet; bei der radiologischen Auswertung waren Schwerpunkte die knöcherne Frakturheilung resp.
cut out bzw. Positionsänderungen der Implantate. Es wurden 50 Patienten mit per-, inter- und subtrochantären Femurfrakturen versorgt. Die Einteilung der Frakturen erfolgte nach der AO - Klassifikation. Die häufigsten Verletzungen waren mit 62,8% 31-A2 Frakturen. Das Durchschnittsalter der Patienten betrug zum
Zeitpunkt der Operation 80,6 Jahre. Der Anteil der weiblichen Patienten überwog mit 80% (n=40).
Results: 10 Patienten verstarben innerhalb des Nachuntersuchungszeitraums. Es resultierte ein 1- Jahres- follow- up von 80 % (40 Patienten). Im Vergleich zu präoperativ erreichten 78,9% nach 12 Monaten
eine analoge Mobilität. Eine vollständige Konsolidation der Fraktur war bei 37 Patienten (92.5%) zu verzeichnen. Drei mussten sich aufgrund einer non-union einer Revisionsoperation unterziehen (Hüfttotalprothese bzw. LFN). Im Rahmen der Nachuntersuchung 6 Wochen postoperativ klagten 6 Patienten über
eine Tractusreizung. Konventionell radiologisch überragte in diesen Fällen die Klinge die laterale Kortikalis
um durchschnittlich 16 mm. Ein Jahr postoperativ waren bei 4 Patienten die Beschwerden vollständig
regredient. Ein Patient beklagte einzig noch, auf der operierten Seite nicht Liegen zu können. Bei einer
Patientin wechselten wir die Klinge gut 6 Monate nach dem primären Eingriff gegen eine kürzere aus. In
3 Fällen (7,5 %) kam es zum cut-out der PFN A- Klinge, in allen Fällen ohne vorangegangenen Sturz. Bei
einer Pat. war bereits in den intraoperativen Bildern ein Ausbrechen der Klinge der Klinge nach cranial zu
verzeichnen, sodass in einem 2. Schritt eine Revisionsoperation erforderlich war, bei einer Patientin war
im Anschluss an die Erstmobilisation radiologisch ein cut out zu sehen, der dritte Patient musste 8 Monate
postoperativ revidiert werden. Insgesamt mussten 7 Patienten wegen Implantat-bezogenen Komplikationen (17,5%) reoperiert werden.
Conclusion: Mit dem PFN A lässt sich eine sichere Frakturversorgung hüftgelenksnaher Femurfrakturen
erreichen. Die Patienten erreichen in der Mehrheit eine gute Gehfähigkeit. Der PFN A ist aus unserer Sicht
ein weiterentwickeltes Implantat, welches gut den Bedürfnissen des osteoporotischen Knochens angepasst wurde; eine optimale chirurgische Technik mit Berücksichtigung einer adäquaten Klingenlänge und
der exakten Klingenlage in center-center Position ist aber weiterhin entscheidend!
53.3
Erste Erfahrungen in der Anwendung der DHS Blade bei proximalen Femurfrakturen
R. Joos, R. Jenni, C. Sommer (Chur)
53.1
Intramedullary stabilization of proximal femur fractures with the new PFN A: retrospective analysis of
231 patients
Ü. Can, J. Forberger, A. Platz (Zürich)
Objective: Intramedullary stabilization has become a standard procedure in the treatment of proximal
femur fractures. New implants as the new PFN A (Synthes) have been developed to reduce complication
rates. Specially reoperation of mostly very old patients with high comorbidity leeds to bad outcome. The
new design of the PFN A with a single spiral blade should bring better fixation in the osteoporotic bone,
resulting in lower complication rates. This retrospective analysis compares the PFN standard with the new
PFN A with special interest in complication and reintervention rates.
Methods: Retrospective Analysis of patients with intertrochanteric fracture treated with intramedullary Nailing with the Proximal Femur Nail PFN standard or since the introduction 3/06 with the PFN A (Synthes).
Based on our clinical information system, all X-rays and patient reports are analysed. Fracture classification according to the AO-Classification, postoperativ reduction, implant position and radiological follow up
in regard to secundary dislocation and implant failure are analysed. All complications, leading to reoperation are registred. Age, sex, length of hospital stay (LOS), surgeon (consultant or resident), comorbidity
(Charlson Index) and functional assessment (Barthel Index) are compared in the two groups.
Results: From 10/2005 to 09/2007 totally 231 patients with proxial femur fractures where treated in the
Surgical Departement of City Hospital Triemli, Zurich. 115 patients with intertrochanteric fractures according the AO-Classification (29 A1, 75 A2, 11 A3) where stabilized with the PFN standard, 116 patients with
the PFN A (40 A1, 61 A2, 15 A3). Data analysis regarding sex, age, comorbidity, functional assessent,
surgical excellence or length of hospital stay shows no difference in the to groups PFN standard vs. PFN
A: Age 82.7/84.4, Female 95/95, Male 20/21, Charlson Index 5/5, Barthel Index 90/95, LOS 15.5/15.9,
Consultant 72/74, Resident 43/44. In the PFN standard group 14 patients needed a reoperation, in 10
cases with partial or total reosteosynthesis including hip replacemet in 1 patient. Additionally 9 hematomas and 2 infection head to be treated by operation. The PFN A group showed only 4 reinterventions
(3 total hip), all do to secondary dislocation or implant failure. There was no reintervention because of
hematoma or infection.
Conclusion: The new design of the PFN A with a single spiral blade an a slightly modified geometry of
58
the nail shows advantages not only in intraoperativ handling but also in significant reduction of postoperativ complications leading to reintervention. This important effect is documented by a clear reduction of
complication and reoperation rate. The introduction of this new implant showed no learning curve, a very
important aspect in a large teaching hospital. Treatment of proximal femur fractures with the new PFN A is
a safe procedure with reduced risk for reoperation of the often very old and polymorbid patient. Nevertheless anatomic reduction, correct implant positioning and careful perioperative patient management are
still the key to succesfull treatment.
Objective: Zur Stabilisierung von Schenkelhalsfrakturen Pauwels 2 und 3 sowie einfachen pertrochanteren Femurfrakturen ist die DHS ein bewaehrtes Implantat. Dennoch findet sich gerade bei porotischem
Knochen eine erhebliche Ausbruchrate des Schenkelhalskrafttraegers („Cut out“). Um dies zu minimieren
wurde die DHS Blade mit Verdichtungseffekt der Femurkopfspongiosa entwickelt. Ziel dieser Studie ist ein
erster Vergleich der DHS-Blade mit der konventionellen DHS bezueglich „Cut out“-Rate und des intraoperativen Handlings.
Methods: Prospektive Datensammlung von 34 konsekutiven Patienten (Durchschnittsalter 74.7 +/- 13.4,
m : f 14 : 20) mit prox. Femurfrakturen (13 x 31-A1, 6 x 31-A2, 2 x 31-B1, 6 x 31-B2 sowie 7 x 31-B3),
welche in der Zeit zw. Nov. 2006 und Nov 2007 im KSGR mittels DHS Blade versorgt wurden. Erfasst wurden Operationsdauer, intraoperatives Handling, intra - und postoperative Komplikationen, BV-Zeit sowie
klinischer und radiologischer Outcome nach 3 und 6 Monaten (Cut-out, Implantatlockerung, Sinterung
und Frakturheilung).
Results: Follow up 88% (30 von 34 Patienten), wie das Patientengut mit hohem Alter erwarten liess, verstarben 2 Patienten vor der ersten Nachkontrolle. 2 Patienten konnten aufgrund eines zu schlechten AZ
nicht nachkontrolliert werden. Die durchschnittliche Operationszeit betrug 67min. Das Implantat wird von
den 11 verschiedenen Operaturen als einfach beurteilt. In einem Fall konnte die Blade intraop. nicht verriegelt werden, sekundaer stellte sich ein Fabrikationsfehler heraus. Im Falle einer Patientin mit schlechter
Compliance und sehr unguenstig medial gelegener Pauwels 3 Fraktur kam es zu einem Abgleiten der
schmalen Femurkopfschale nach dorsal ohne eigentlichen Cut-out. Die restlichen 28 Frakturen heilten
komplikationslos aus mit einer durchschnittlichen Sinterungsrate auf Frakturhoehe von 3mm (2-8mm).
Conclusion: Bei technisch korrekter Anwendung des Implantates gilt die Osteoporose als wesentlichste
Ursache fuer ein Durchschneiden der Schraube durch den Kopf (Cut out). Mit zunehmendem Alter der
Patienten nimmt die Zahl der osteoporosebedingten proximalen Femurfrakturen zu. In der Literatur wird
bei Versorgung mit der konventionellen DHS eine Cut out-Rate von 9 -15 % beschrieben. Gemaess unseren ersten Erfahrung scheint die DHS Blade eine erfolgversprechende Weiterentwicklung zur Reduktion
des Cut outs darzustellen. Trotzdem ist auch bei diesem Implantat ein korrektes techisches Vorgehen mit
moeglichst anatomischer Frakturreposition und korrekter Schraubenlage unabdingbar.
53.4
Prospective clinical evaluation of intraoperative bone strength measurement in fixation of proximal femoral fractures
A. Müller1, M. Hirschmann2, N. Suhm1 (1Basel, 2Bruderholz)
Objective: In 3-5% of cases, fixation of proximal femoral fractures is complicated by implant loosening
leading to secondary dislocation and cut out of the hip screw through the femoral head. Besides inappropriate implant position and fracture reduction, impaired bone strength due to osteoporosis is a leading
cause of such failure. While technical shortcomings can be assessed and corrected intraoperatively, a
standardized, intraoperative evaluation of bone strength indicating possible need for augmentation has
so far been missing. Here, we tested if bone strength can safely be assessed with an intraoperative, torque
based measurement technique and if torque values correlate with bone mineral density (BMD) measured
by dual x-ray absorptionmetry (DXA) – the gold standard osteoporosis diagnostic – and with postoperative implant loosening or screw cut out.
Methods: Patients older than 40 years who sustained a proximal femoral fracture suitable for fixation with
dynamic hip screw (DHS) were enrolled in the study. Patients with local infections or pathologic fractures
were excluded. Intraoperatively- prior to hip screw insertion- a cannulated probe with a wing blade like tip
was inserted to reach the site of the intended DHS tip. While rotating the probe around its longitudinal axis,
peak torque to breakaway cancellous bone between the wings of the probe was measured. Presence of
correct fracture reduction (i.e. angle between the femoral head’s compression trabeculae and the femoral
shaft’s longitudinal axis >160° in the ap view and 180° in the lateral view) and appropriate screw position
(i.e. placement in the inferior-posterior quadrant of the femoral head, distance between the screw tip and
apex of the femoral head < 20mm) was assessed on plain radiographs. Peak torque was related to BMD
(g/cm2) of the femoral neck measured by postoperative DXA as well as implant loosening and screw cut
out assessed on plain radiographs 6 and 12 weeks postoperatively. Moreover, time needed for intraoperative measurement was noted.
Results: From January until December 2007, 31 consecutive patients (19 female, 12 male mean age:
63.5) with 31 pertrochanteric fractures (13 AO31A1, 8 A31A2, 3 AO 31A3) and 7 lateral femoral neck
fractures eligible for DHS fixation were enrolled in the study. So far, 10 patients have undergone postoperative DXA measurement and six weeks follow-up, while 12 week follow up has been completed in 21
patients. No major complication occurred during intraoperative torque measurement. Mean time for intraoperative torque measurement was 2.8±1.6min accounting for 2.5±1.5% of total surgery time. Correct
fracture reduction could be achieved in all cases, while the mean distance between the DHS tip and the
apex of the femoral head was 22 ± 6mm. Peak torque showed correlation with BMD values measured
in the femoral head by postoperative DXA (R= 0.8). In the present follow-up period, no screw cut out has
been observed.
Conclusion: Intraoperative torque measurement is a safe and fast procedure, fully adapted to DHS implantation and possibly able to predict implant loosening and screw cut in correlation with BMD values.
Its value will be further assessed in a multicenter trial.
53.5
Reversed LISS-DF in complex proximal femur fractures
Y. Acklin, H. Bereiter, C. Sommer (Chur)
Objective: The treatment of complex proximal femur fractures is challenging and a broad spectrum of
implants are available. Never the less, many implants fail in the postoperative course on one hand. On the
other hand, the use of a proximal femoral nail (PFN or Gamma Nail) can lead to a disturbing insufficency
of the pelvitrochanteric muscles due to the large entry canal. To improve these problems, we started to
use the well known LISS-DF (less invasive stabilization system for the distal femur) in an opposite way for
complex proximal fracture situations. The goal of this study was to evaluate the range of application and
the first clinical results of the LISS-DF in proximal femur fractures.
Methods: All complex proximal femur fractures treated with a reversed LISS-DF between 01/2005 and
12/2007 were evaluated. The indications for internal fixation with a reversed LISS-DF were multifragmentary trochanteric or subtrochanteric fractures, mainly in younger patients.
Results: A cohort of thirteen proximal complex femur fractures was operated with a LISS-DF. The median
age was 54 ranging from 10 to 77. According to the AO classification, there were eight 31-A3, one 31-A2,
two 32-C1 and two pathological fractures. No intra-operative complications were recorded. Except for the
two pathological fractures, all fractures could be treated with a minimal invasive approach.
Conclusion: The LISS as a pre-bent internal locking system has shown excellent results in the treatment
of distal femur fractures. In the reversed contra-lateral application, this procedure is a minimally invasive
technique and can be a good alternative to other implants as IM-nails or other plates.
53.6
Minimally invasive hip hemiarthroplasty for femoral neck fractures: first results
Ü. Can, A. Platz (Zürich)
Objective: Minimally invasive Surgery (MIS) for total hip arthroplasty has become a standard procedure
in elective orthopedic Surgery. The advantages of the MIS technique are less soft tissue trauma, therefore
less pain, earlier mobilisation and better rehabilitation. MIS for femoral neck fractures should bring the
same advantages, but so far, very little is known in the literature. We report our experience introducing MIS
hip in Trauma patients and comment the first results.
Methods: Consecutive data collection of all patients, treated with MIS hemiarthroplasty in femoral neck
fractures. Technique: Patient in suppine position, no special table, direct anterior approach, special MIS instruments (Stryker), cemented ABGII Shaft with monopolar head. Data collection includes intraoperative
problems, operating time, postoperative complications, length of hospital stay, postoperativ Timed up and
go test (TUG), Harris Hip score and x-ray analysis 6 weeks postop.
Results: Starting 12/2006 12 patients (7female/5male) average age 88(74-100) are operated in the
MIS technique. Operating time: 98 min(78-120), LOS 12.5 (2-28). Timed up and go Test TUG: 42.29 sec.
No intraoperative complication, 2 patients died during hospitalisation (1 leucemia, 1 severe dementia),
1 reintervention because of wound dehiscence. Harris hip score after 6 weeks: 87.64. Correct implant
positioning in all patients.
Conclusion: Hemiarthroplasty in MIS technique for Trauma patients is feasible and can produce very good
results in term of pain, early mobility and patient satisfaction. Starting the technique, the trauma surgeon
has to be aware of a existing learning curve. In contrast to elective surgery, case load for the single trauma surgeon takes his time. The first results are very promissing, nevertheless critical application of this
new method in trauma patients seems to be reasonable. If all patients can be treated by all surgeons
in every hospital with MIS remains unclear. Evidence is not yet available, even not in elective total hip
replacement.
53.7
Nachkontrollstudie von Tibiaplateaufrakturen AO 41 B1- C3 mit 3.5 mm Radius T-Platte
H. Fenner, R. Babst (Luzern)
Objective: Zur Behandlung der Tibiaplateaufrakturen stehen diverse Implantate zur Verfügung. Unsere
retrospektive Evaluation betrachtet das subjektive wie auch objektive Resultate nach Tibiaplateauostesosnyhtese, die mit einer 3.5 mm Radiusplatte stabilisiert wurden.
Methods: Im Zeitraum von 01/1998 und 12/2005 wurden von uns 152 Tibiaplateaufrakturen bei monound polytraumatisierten Patienten mit Plattenosteosynthese versorgt. Hiervon wurden 102 Patienten mit
einer nicht winkelstabilen 3,5 mm Radius T Platte (Synthes) mit oder ohne Knochensubstitution versorgt.
47 Patienten konnten wir im Median nach 59.34Monaten klinisch und auch durch einen Fragebogen,
der den SF 36, den Tegner Aktivitätsscore , die visuelle analoge Schmerzskala (VAS) und den Lysholmscore beinhaltete, evaluieren. Radiologisch wurden 34 Patienten postoperativ, 6 Wochen und nach 58,24
Monaten hinsichtlich Primär- und Sekundärdislokation, Implantatbruch, Verhalten von Knochensubstituten, Zunahme der Arthrose und Implantatversagen evaluiert. Ziel war die Erfassung der subjektiven
Zufriedenheit in Abhängigkeit von den objektivierbaren Daten durch die klinische Untersuchung und der
radiologischen Auswertung.
Results: Von den 102 Patienten konnten 47 (Durchschnittsalter 47,0 Jahre) Patienten mit 42 AO 41 B,
und 5 AO 41 C Frakturen klinisch und durch die Fragebogen evaluiert werden. Es besteht bei 34 (Durchschnittsalter 52,4 Jahre) von 47 Patienten ein radiologischer Follow up direkt postoperativ (Median1,76
Tage), nach 6 Wochen (Median 6,31 Wochen) und nach 58,24 Monaten im Median. Hierbei zeigte
sich bei einer AO 41 C3 Fraktur eine Dislokation, die eine Reosteosynthese mit grösser dimensionierte
winkelstabilen Platten bedurfte. Desweiteren wurden bei den übrigen 33 Patienten keine primären oder
sekundären Dislokationen, noch ein Implantatbruch beobachtet. Das Resorptionsverhalten von Norian
SRS® (16 von 34) liess sich anhand der Verlaufsbeobachtung durch konventionelle Röntgenbilder nicht
konklusiv beurteilen. Lediglich bei 2 Patienten fand eine vollständige Resorption statt. Eine Zunahme der
Arthrose klassifiziert nach dem Arthroseindex nach Jäger-Wirth wurde bei 17 Patienten um 1° und bei 3
Patienten um 2° beobachtet. Eine schwere Gonarthrose lag weder vor dem Unfall noch anlässlich der
Nachkontrollen vor (Ahlbäck Score 0). Bei 13 Patienten zeigte sich ein Extensionsdefizit von 4.7° Grad
(2°-15°) , bei 15 Patienten ein Flexionsdefizit von 9.5° Grad (2°-30°) im Vergleich zur nicht verunfallten
Seite..Die Narbenlänge lag bei 11 cm im Median. Im SF 36 hatten vorallem die Altersgruppe zwischen 2140 Jahren schlechterer Resulate als ein gesundes Normalkollektiv, während in der höheren Altergruppe
ab 40 keine Differenz mehr zu den Gesunden bestand. Im Tegner Score erreichten 32 Patienten einen
gleichen Aktivitätslevel wie präoperativ. Bei 15 Patienten verringerte sich die körperliche Aktivität. Der Median im VSA lag bei 20.81 (1-80). Lysholmscore Median 81.91 (14-100).
Conclusion: Die Stabilisierung von Tibiaplateaufrakturn mit 3.5 mm Implantaten ist für monocondyläre
Frakturen genügend. Damit wird der Zugang minimiert und das Implantat trägt weniger auf als grösser
dimensionierte Implantate. Zwischen autologem heterologem Knochenersatz bestand hinischtlich Sekundärdislokation kein Unterschied. Bei bicondylären Frakturen eignen sich diese Implantate nicht für die
bilaterale Versorgung.
53.8
Operative Stabilisation von Moore Typ II Frakturen (Entire Condyle) des Tibiaplateaus über einen direkten dorsalen Zugang
A. Brunner, R. Babst (Luzern)
Objective: Tibiakopffrakturen sind haeufig und zeigen eine grosse Vielfalt an Frakturtypen und ligamentaeren Begleitverletzungen. Die operative Stabilisation erfordert dementsprechend eine genaue Planung
des operativen Zugangs sowie spezifische Osteosynthesetechniken. In der Mehrzahl der Faelle laesst
sich der Tibiakopf ueber einen anterolateralen Standard-Zugang reponieren und stabilisieren. Die Moore
II Fraktur (Entire Condyle) repraesentiert ein spezielles, hochgradig instabiles Frakturbild, welches weder
von der Schatzker- noch von der AO-Klassifikation genuegend umfassend beschrieben wird. Die Fraktur verlaeuft in der Regel vom gegenueberliegenden Kompartiment des Plateaus in einem Winkel von
45 Grad durch den Kondylus der betroffenen Seite. Die Eminentia intercondylaris ist haeufig abgerissen
und das gegenueberliegende Kollateralband rupturiert. In der Literatur finden sich bis dato kaum Empfehlungen bezueglich der operativen Stabilisierung dieses spezifischen Verletzungsmusters. Galla und
Lobenhofer beschrieben 2003 einen wenig invasiven, direkten dorsalen Zugang auf den Tibiakopf zur
Reposition und Osteosynthese von „Medial Splint Frakturen“. Seit 2003 wird diese Technik in unserer
Abteilung auch zur Versorgung von Moore Typ II Frakturen eingesetzt. Berichtet werden erste klinische
Erfahrungen und Fruehergebnisse nach Verwendung dieser Technik.
Methods: Zwischen 2003 und 2007 wurden 6 Patienten mit Moore Type II (Entire Condyle) Fraktur durch
denselben Operateur ueber den direkten dorsalen Zugang versorgt. Das durchschnittliche Alter der Patienten zum Zeitpunkt der Operation betrug 37 Jahre. Alle Patienten konnten nach 6 und 12 Wochen, sowie
nach einem medianen Follow up von 31 Monaten klinisch und radiologisch nachuntersucht werden. Des
Weiteren wurden die Resultate mittels SF36, WOMAC und Lysholm Score objektiviert.
Results: Bei keinem der Patienten trat intraoperativ eine Komplikation auf. Postoperativ fand sich in einem
Fall ein Wundinfekt, welcher revidiert werden musste. Nach bereits 12 Wochen fand sich bei 5 Patienten
59
eine gute Beweglichkeit, insbesondere eine volle Streckfaehigkeit. Saemtliche Patienten zeigten sich sehr
zufrieden mit dem postoperativen Ergebnis. Des Weiteren konnten alle Patienten ihre fruehere berufliche
Taetigkeit wieder aufnehmen.
Conclusion: Der direkte dorsale Zugangsweg stellt eine gute Option zur Versorgung instabiler Moore Typ II
(Entire Condyle) Frakturen dar. Die fruehen klinischen Ergebnisse sind vielversprechend. Weitere Studien
mit groesseren Fallzahlen werden folgen, um die Wertigkeit dieser Methode, insbesondere in Hinblick auf
Langzeitergebnisse, zu untermauern.
53.9
Aetiologien der posttraumatischen Sprunggelenksarthrose
M. Horisberger1, V. Valderrabano1, B. Hintermann2 (1Basel, 2Liestal)
Objective: Circa 1% der Bevölkerung ist von einer Sprunggelenksarthrose betroffen. Diese ist damit im
Vergleich zu Knie- und Hüftarthrose viel seltener, die Inzidenz zeigt aber steigende Tendenz und die Patienten sind deutlich jünger. Die Mehrzahl der Fälle sind posttraumatischer Aetiologie. Die Entstehungsmechanismen und zeitlichen Dimensionen der posttraumatischen Sprunggelenksarthrose sind erst ungenügend bekannt. Ziel der Studie war es, Aetiologien, Pathomechanismen und prädisponierende Faktoren
zu identifizieren, welche zur Entwicklung und Progression einer posttraumatischen OSG-Arthrose nach
sprunggelenksnaher Fraktur führen.
Methods: Zwischen 1996 und 2003 wurden 257 konsekutive Patienten (270 Fälle) mit endgradiger
OSG-Arthrose registriert. 141 posttraumatische Fälle konnten in die Untersuchung eingeschlossen werden (Männlich n= 58; weiblich n= 83). Aufarbeitung von Daten aus der Krankengeschichte, der klinischen
Untersuchung und radiologischen Befunden. Analyse von Arthrose-Latenzzeit (Zeit von Fraktur bis endgradiger OSG-Arthrose), Frakturtyp (nach AO-Klassifikation und Hawkins), Behandlungsmethoden, Komplikationen in der Frakturheilung, Weichteilsituation, Alter, AOFAS Hindfoot Score, Bewegungsumfang,
radiologisches Alignement.
Results: Das durchschnittliche Alter zum Zeitpunkt der endgradigen OSG-Arthrose lag bei 55.7 Jahre (2283 Jahre). Die Latenzzeit betrug durchschnittlich 20.9 Jahre (1-52 Jahre). Malleolarfrakturen waren die
häufigste Fraktur (53.2%), gefolgt von distalen Tibiafrakturen (29.1%). Eine negative Korrelation zwischen
Latenzzeit und Frakturschwere konnte für einige Frakturtypen beobachtet werden (Distale Tibiafrakturen:
r=-0.4, p<0.01). Patienten, die im Heilungsverlauf Komplikationen entwickelten zeigten eine signifikant
kürzere Latenzzeit (p<0.01). Das Patientenalter zum Zeitpunkt des Unfalls korrelierte negativ mit der
Latenzzeit (r=-0.6, p<0.01). Die angegebenen Schmerzen betrugen 7.2 Punkte (VAS, 2-10 Punkte), der
Bewegungsumfang lag bei 19.7° (0°-50°), der durchschnittliche AOFAS Hindfoot Score erbrachte 36.3
Punkte (0-72 Punkte). In der radiologischen Analyse war das Alignement mit 88.8° (63-110°) durchschnittlich varisch.
Conclusion: Unter den traumatischen Ursachen der OSG-Arthrose dominieren die Malleolar- und distalen
Tibiafrakturen. Die Latenzzeit bis zur endgradigen OSG-Arthrose ist länger als allgemein vermutet und beträgt durchschnittlich 20.9 Jahre. Es zeigt sich eine Abhängigkeit der Latenzzeit von Frakturtyp/-schwere,
Auftreten von Komplikationen und patientenbezogenen Faktoren wie das Alter zum Zeitpunkt der Fraktur.
Die Studie belegt die überragende Wichtigkeit von sprunggelenksnahen Frakturen als Hauptursache der
OSG-Arthrose und erlaubt eine Prognose über die zeitliche Entwicklung einer posttraumatischen OSGArthrose.
54.2
Antibiotikaprophylaxe bei Entfernung von Urinkathetern verhindert Harnwegsinfektionen – eine randomisierte prospektive Studie
U. Pfefferkorn, L. Sanlav, J. Moldenhauer, R. Peterli, C. Ackermann, M. von Flüe (Basel)
Objective: Die Studie untersucht, ob die Antibiotikaprophylaxe bei Entfernung von Urinkathetern Harnwegsinfektionen verhindert.
Methods: Unsere prospektive randomisierte Studie rekrutierte 239 Patienten mit elektiven Abdominaleingriffen, welche randomisiert wurden, bei Urinkatheterentfernung eine Antibiotikaprophylaxe mit drei Dosen Trimethoprim-Sulfamethoxazol zu erhalten oder nicht. Urinkulturen wurden vor und drei Tage nach
Urinkatheterentfernung durchgeführt. Subjektive Symptome wurden durch einen unabhängigen und verblindeten Urologen erfasst. Harnwegsinfektionen wurden gemäss den Definitionen des amerikanischen
Centre of Disease Control diagnostiziert.
Results: Patienten, die eine Antibiotikaprophylaxe erhielten zeigten signifikant weniger Harnwegsinfektionen (5/103, 4.9%) als jene ohne Prophylaxe (22/102, 21.6%), p<0.001. Die Reduktion des absoluten
Risikos betrug 16.7%, diejenige des relativen Risikos 77.3%. Um eine Harnwegsinfektion zu vermeiden
mussten sechs Patienten behandelt werden. Signifikant weniger Patienten mit Antibiotikaprophylaxe
zeigten eine signifikante Bakteriurie drei Tage nach Katheterentfernung (17/103, 16.5%) als diejenigen
ohne (42/102, 41.2%), p<0.0001.
Conclusion: Die Antibiotikaprophylaxe mit Trimethoprim-Sulfamethoxazol bei Entfernung von Urinkathetern führt zu einer signifikanten Abnahme der Häufigkeit von symptomatischen Harnwegsinfektionen
und signifikanten Bakteriurien bei Patienten, die für einen elektiven Abdominaleingriff perioperativ einen
Urinkatheter benötigen.
54.3
Equal effectiveness of 1.5 versus 3 minutes of surgical hand antisepsis with an alcoholic hand rub
W.P. Weber, S. Reck, R. Saccilotto, W.R. Marti, D. Oertli, A. Widmer (Basel)
54.1
Objective: Alcohol-based hand rubs offer several advantages for surgical hand antisepsis in comparison with antimicrobial soaps, and are considered as standard of care by the World Health Organization
(WHO).The European standard EN 12791 requires 3 minutes application time, but some products meet
the defined antimicrobial effectiveness in in-vivo experimental studies after an application of only 1.5 minutes. We evaluated the short duration of surgical hand antisepsis in a clinical setting by comparing the
effectiveness of 1.5 versus 3 minutes with a commercially available agent (Sterillium® classic pure).
Methods: Prospective randomized trial at Basel University Hospital involving 32 surgeons with different
levels of post-doc training and from different surgical specialties in a crossover design following the guidelines outlined in EN 12791. The three hours sample after application, required to assess the residual
activity under the gloved hand, was adapted to “after surgery”. The outcome of interest in this study was
the antibacterial effectiveness of surgical hand antisepsis with Sterillium® classic pure by determining
the colony-forming units before and after the application of Sterillium® classic pure (immediate effect)
and after the procedure (sustained effect) to follow EN 12791 as close as possible. The primary predictor
variable was surgical hand antisepsis duration of 1.5 versus 3 minutes. The logarithmic reduction factor
was calculated as the difference between the log10 baseline value and the log10 post-application value.
Results: With regard to the immediate effect the mean reduction factor was 2.66 ± 1.13 and 3.01 ± 1.06
for the 1.5 minutes and 3 minutes group, respectively (p=0.204). Similarly, there was no statistically significant difference in the sustained effect between the two groups with a mean log10 increase of 1.08 ±
1.13 and 0.95 ± 1.27, respectively, during surgery (p=0.708). The mean duration of surgery did not substantially differ between the two groups (82.9 minutes [standard deviation 50.3] versus 105.3 minutes
[standard deviation 78.2] for the 1.5 minutes and 3 minutes group, respectively; p=0.38).
Conclusion: The reduced application time of 1.5 minutes achieves a similar reduction factor as 3 minutes
with the alcoholic hand rub. Given the frequency of the procedure, these results allow a considerable time
saving while maintaining effectiveness.
The timing of surgical antimicrobial prophylaxis
W.P. Weber1, W.R. Marti1, M. Zwahlen2, H. Misteli1, R. Rosenthal3, S. Reckv, P. Fueglistaler1, M. Bolli4,
D. Oertli1, A. Widmer1 (1Basel, 2Bern, 3Lausanne, 4Homburg-Saar/DE)
54.4
54
Objective: Under today’s recommendations, antibiotics may be administered within the final two hours
prior to skin incision, ideally as close to incision time as possible. The administration of prophylactic antibiotics within the final half hour before skin incision, however, may not suffice for optimal prevention of
Surgical Site Infections (SSI). The primary objective of the present study was to obtain precise information
on the optimal time window for surgical antimicrobial prophylaxis.
Methods: In this prospective observational cohort study at Basel University Hospital we tested the hypothesis that the risk of SSI was lower when surgical antimicrobial prophylaxis was applied earlier than
30 minutes before surgery than when administered in the final half hour before surgery. We therefore
analyzed the incidence of SSI by the timing of antimicrobial prophylaxis in a consecutive series of 3836
surgical procedures. Surgical wounds and resulting infections were assessed to Centers for Disease Control and Prevention standards. Antimicrobial prophylaxis consisted in single-shot administration of 1.5 g of
second-generation cephalosporin cefuroxime (plus 500 mg of metronidazole in colorectal surgery).
Results: The overall SSI rate was 4.7% (180 of 3836). In 49% of all procedures antimicrobial prophylaxis was administered within the final half hour before surgery. Multivariable logistic regression analyses
showed a significant increase in the odds of SSI when antimicrobial prophylaxis was administered less
than 30 minutes (crude odds ratio = 2.01; adjusted odds ratio = 1.95; 95 percent confidence interval, 1.4
to 2.8; p<0.001) and 120 to 60 minutes (crude odds ratio = 1.75; adjusted odds ratio = 1.74; 95 percent
confidence interval, 1.0 to 2.9; p=0.035) as compared to the reference interval of 59 to 30 minutes before
incision.
Conclusion: When cefuroxime is used as a prophylactic antibiotic, administration 59 to 30 minutes before
incision is more effective than administration during the last half hour.
60
A crossover intervention trial to evaluate the impact of rapid on-admission screening in preventing Methicillin-Resistant Staphylococcus Aureus (MRSA) infection after surgery
S. Harbarth, C. Fankhauser, J. Schrenzel, P. Gervaz, J. Christenson, Ph. Morel, H. Sax, D. Pittet (Genève)
Objective: Carriage of Methicillin-resistant Staphylococcus aureus (MRSA) places patients at risk for
subsequent postoperative MRSA infection. Experts have repeatedly called for widespread admission
screening to reduce nosocomial MRSA infection. The objective of this study was to determine the impact
of a pre-emptive MRSA detection strategy on nosocomial MRSA infection in a cohort of 21,754 surgical
patients operated in a single teaching institution.
Methods: We carried out a prospective, interventional cohort study using a crossover design to compare two different MRSA control strategies (rapid screening plus standard control versus standard control
only). Twelve surgical units were assigned to two study groups and enrolled patients according to a prespecified agenda, encompassing 4 study phases. Patients admitted for > 24 hours were screened for
MRSA carriage upon admission by quick, multiplex Polymerase Chain Reaction (PCR).
Results: Overall, 10,193 out of 10,844 (94%) patients were screened in the intervention units. Screening
identified 515 MRSA-positive patients (5%), including 337(65%) previously unknown MRSA carriers and
120 patients (23%) in whom the positive results of admission screening were only known after surgery. In
the intervention periods, 93 patients (1.11 per 1,000 patients-days) acquired MRSA infection, compared to
76 in the control period (0.91 per 1,000 patients-days; adjusted incidence rate ratio, 1.2; 95% Confidence
Interval 0.9-1.6, p=0.16). The rates of MRSA surgical site infections and nosocomial MRSA acquisition did
not change significantly. Fifty-three of 93 infected patients (57%) in the intervention units were MRSA-free
on admission and acquired MRSA infection later during hospitalization.
Conclusion: A universal, rapid on-admission screening strategy did not reduce nosocomial MRSA infections in a surgical department with endemic MRSA, but low (1%) rates of infection. The majority of
MRSA infections are due to acquisition of MRSA during the hospital stay in patients previously non-MRSA
carriers.
54.5
Internet habits of surgical patients – what information do they look at prior to their elective admission?
U. Pfefferkorn, A. Businger, C. Ackermann, M. von Flüe (Basel)
Objective: The use of the internet is becoming increasingly common for gathering medical information
and most hospitals in Switzerland are offering information on a internet website. This study examines the
internet habits regarding medical information of surgical patients prior to their elective admission.
Methods: To examine the internet habits of elective surgical patients prior to admission, we performed
a survey with a questionnaire over a one-month period. The following data were recorded : Access to
internet, visit to hospital website, visit to other medical websites, information looked at on hospital website
and influence of hospital website on choice of hospital.
Results: 218 of 225 patients (96.9%) filled in the questionnaire during the observation period, of which
152 (69.7%) had access to the internet at home or at work. 74/218 (33.9%) patients had visited a medical website prior to admission. 42/74 (56.8%) patients had visited our hospital website and 52/74
(70.2%) had visited other medical websites, p=0.06, n.s. The information looked at by visitors on our
hospital website is listed in table 1. Only one patient looked at the annual report including the annual
numbers of operations. What information patients looked at was not dependent on age, sex or type of
insurance. Only 4/218 (1.8%) patients stated that their choice of hospital was influenced by having visited
our hospital website.
Conclusion: One third of surgical patients are using the internet to find medical information prior to their
elective admission. They do not limit their search to the website of the hospital of their choice. Most patients are not using the internet as means to choose a hospital.
54.6
Die Risiken reduzierter Arbeitszeit
B. Muff (Bülach)
Objective: Vor 14 Jahren haben wir im Spital Bülach ein Job-Sharing Modell für das Kader in der Chirurgie erarbeitet. Seither haben wir verschiedene Teilzeitmodelle ausprobiert und eine grosse Erfahrung in
der Umsetzung auf allen Hierarchiestufen erlangt. Bereits 1997 am Jahreskongress der SGC in Davos
haben wir über die ersten Erfahrungen der Arbeitszeitflexibilisierung berichtet, damals v.a. über die Voraussetzung, Konsequenzen und die praktische Umsetzung. Über die Risiken und die Grenzen, die solche
Modelle beiinhalten, fehlte uns jedoch die Erfahrung.
Methods: Die Erfahrungen von 14 Jahren Teilzeitmodellen auf allen Hierarchiestufen der Chirurgischen
Aerzteschaft im Spital Bülach werden aufgearbeitet und die daraus resultierenden Konsequenzen für die
Arbeitszeitmodelle aufgezeigt. Insbesondere werden die Risiken, Gefahren und die Grenzen der verschiedenen Modelle aufgezeichnet und mögliche notwendige Rahmenbedingungen aufgezeigt.
Results: Arbeitszeitflexibilisierung für Führungskräfte macht v.a. dann Sinn,wenn dabei die kontinuierliche
Weiterbildung und auch die Karriereförderung berücksichtigt werden. Es hat sich gezeigt, dass JobSharing Modelle einfacher umsetzbar sind als alle anderen Teilzeitmodelle. Die Wahrnehmung von Führungsfunktionen und Managementaufgaben verlangen eine minimale Präsenzzeit Es gibt es eine untere
Beschäftigunggrenze. unter welcher eine genügende Routine nicht mehr gewährleistet ist. Dies kann zu
Angstzuständen mit entsprechender Übervorsicht und Fehlentscheiden führen.
Conclusion: Die Umsetzung von Arbeitzeitmodellen in der Chirurgie hat zweifelsfrei zu einer erhöhten Lebensqualität für die Betroffenen geführt. Es gilt jedoch verschiedene Bedingungen zu berücksichtigen, um
Teilzeitmodelle erfolgreich anzuwenden. Inhalt des Vortrages sind die Voraussetzungen, die Grenzen und
die Gefahren, welche die verschiedenen Teilzeitmodelle aufweisen.
54.7
Gefährdet das grundsätzlich laparoskopische Vorgehen bei Appendizitis die Weiterbildung zum Chirurgen? Auswertung der AQC-Daten 2005 und 2006
S. Pohle, A. Keerl, T. Kocher (Baden)
Objective: Appendektomien machen einen wesentlichen Teil der chirurgischen Notfalleingriffe aus und
sind ein essentieller Bestandteil der chirurgischen Weiterbildung (WB). Zur Erlangung des Schweizer
Facharzttitels fuer Chirurgie ist gemaess WB-Programm vom 1.7.2006 eine Mindestzahl von 20 Appendektomien erforderlich. Es wurde untersucht, ob das grundsaetzlich laparoskopische Vorgehen die WB
zum Facharzt fuer Chirurgie gefaehrdet.
Methods: Vom 1.1.2005 bis zum 31.12.2006 wurden alle am Kantonsspital Baden durchgefuehrten Appendektomien prospektiv ueber das elektronische Tool der Arbeitsgemeinschaft fuer Qualitaetssicherung
in der Chirurgie (AQC) erfasst. 15 Aerzte im ersten und zweiten Weiterbildungsjahr kamen als Operateure
in Betracht. Die Eingriffe wurden mit der von der AQC zur Verfuegung gestellten Datenbank und Software
retrospektiv ausgewertet.
Results: Von 573 Patienten wurden 50 primaer offen und 523 primaer laparoskopisch appendektomiert.
Aufgrund des Versicherungsstatus verblieben 432 Patienten, welche potentiell von Aerzten in WB operiert
werden konnten. Davon wurden 30% der offenen und 79% der laparoskopischen Appendektomien durch
einen Assistenzarzt ausgefuehrt. 69% dieser Eingriffe wurden im Notfalldienst operiert. Der Vergleich
zwischen Kaderarzt und Arzt in WB zeigt keine Unterschiede in der OP-Zeit (Kaderaerzte operieren komplexere Faelle), bei der Rate postoperativer Komplikationen sowie der durchschnittlichen postoperativen
Liegezeit (2.9 vs. 3.09 Tage). Aerzte in WB fuehren in den ersten beiden Jahren der chirurgischen WB im
Durchschnitt mehr als 20 Appendektomien durch.
Conclusion: Das konsequente laparoskopische Vorgehen bei Appendizitis gefaehrdet die chirurgische
Weiterbildung nicht. Diese Operation ist sicher und komplikationsarm vom jungen Chirurgen in WB durchfuehrbar. Die hoehere technische Anforderung hat keinen negativen Einfluss auf die Operationszahlen
junger Assistenten. Diese fuehren die Operation ebenbuertig und in gleicher Zeit wie Fachaerzte durch.
54.8
The AQC database represents a useful tool for quality control and scientific analysis of acute appendicitis
U. von Holzen, A. Gehrz, L. Meier, M. Zuber (Olten)
Objective: Many surgical departments in Switzerland are members of the working group for quality assurance in surgery (Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie - AQC). The purpose of
this study was to assess the value of the AQC database as a tool for quality assurance and source for scientific studies. To meet our goal, we have chosen acute appendicitis as it is a frequent condition. We had
two hypotheses: first, that the percentage of laparoscopic appendectomies increased over time without
an increase of the complication rate, and second that these procedures were primarily performed by
residents according to our teaching concept.
Methods: All appendectomies performed from 2001 to 2006 at the Department of Surgery, Kantonsspital Olten, were prospectively recorded in the AQC database. Among other parameters, the patients` demographics, the type of procedure (laparoscopic versus open), and the status of the surgeon (resident,
junior staff, senior staff) performing the procedure were recorded. Statistical compairisons were based
on Fisher’s exact test.
Results: Overall, 684 appendectomies were performed (300 in women, 384 in men). The subset, in
which the procedure was performed most frequently, was aged 10 to 29 years. From 2001 to 2006,
we recorded a clear increase in the use of laparoscopic interventions from 51% to 81% of all procedures
performed. Ninety-three percent of these appendectomies were performed by the junior faculty or the
residents. Furthermore, we could demonstrate a significant increase in the proportion of laparoscopic
procedures performed by residents from 7% in 2001 to 44% in 2006 (from 4/57 to 44/99 procedures,
p<0.01), as well as an overall increase in the absolute number of procedures performed by residents
(from 18 in 2001 to 52 in 2006). The main complications in our study were deep wound infections in
3.6% of the open procedures as compared to no deep wound infections in laparoscopic procedures.
Intra-abdominal abscess formation was recorded in 2.7% of laparoscopic procedures as compared to
1.8% in open surgery. The overall complication rate in the study was 5.4% with no statistical difference
between open (6.5%) and laparoscopic (4.7%) surgery.
Conclusion: The study clearly shows that the AQC database offers a wide variety of possibilities for quality
assurance and scientific analyses. Our data demonstrate that the percentage of laparoscopic procedures
increased clearly from 2001 to 2006. Appendectomies were mainly performed by residents and junior
faculty at our hospital according to our teaching concept. The laparoscopic appendectomy is a safe procedure with a low complication rate.
54.9
DRG – Anforderungen an das Klinikinformationssystem
F. Bauknecht (Wetzikon)
Objective: Mit der Einführung von DRG kommen neue Anforderungen an das Klinikinformationssystem
(KIS) eines Spitals dazu. Es wird in Zukunft noch wichtiger sein, dass die ICD- und CHOP-Codierung zeitgleich mit der medizinischen Dokumentation erfolgen wird. Denn aufgrund des DRG wird festgelegt, wie
lange ein Patient aus betriebswirtschaftlicher Sicht optimalerweise im Spital sein darf (Ampelsystem).
Kliniken werden sich Ueberlegungen machen müssen, wie Behandlungspfade eingeführt werden können, die sowohl die Qualität der Behandlung gewährleisten als auch die betriebswirtschaftliche Sicht
mitberücksichtigen. Behandlungspfade müssen durch das KIS abgebildet werden können und somit den
Arzt bei der Behandlung direkt unterstützen.
Methods: Voraussetzung für eine optimale Codierung ist die Dokumentation aller Diagnosen und durchgeführten Behandlungen. Dem Codierer müssen alle relevanten Befunde zur Verfügung stehen. Wird heute vorwiegend nach dem Austritt des Patienten codiert, wird mit Einführung von DRG die Codierung im
Behandlungsprozess nach vorne rutschen müssen, damit bei Eintritt bereits ungefähr feststeht, wie lange
ein Patient hospitalisiert bleiben sollte (Inlayer, Outlayer). Somit wird die Codierung nicht mehr nur durch
Proficodierer am Ende der Hospitalisation durchgeführt werden können, die Codierung muss laufend
stattfinden. Hier soll das KIS Unterstützung bieten, z.B. mit Hitlisten, einem Thesaurus mit vorprogrammiertem Cross-Mapping von Diagnosentexten und Ordnungssystemen oder wissensbasierten Lösungen
zur Analyse des Diagnosentextes und automatischer Verschlüsselung (semantische Kodierung).
Results: Anhand einiger Beispiele wird gezeigt, wie DRG-Anforderungen im KIS umgesetzt werden können.
Conclusion: Die Einführung von DRG wird neue Anforderungen an ein Klinikinformationssystem (KIS) bringen. Die Codierung muss zeitnah der Behandlung stattfinden, Behandlungspfade müssen durch das KIS
abgebildet werden können. Systeme mit semantischer Interpretation sollen den Arzt dabei unterstützen.
Visceral Surgery
55
55.1
Résultats d’une étude portant sur 606 hépatectomies: évaluation du risque actuel des résections hépatiques
A. Andres, P. Majno, Ph. Morel, P. Gervaz, S. Terraz, L. Rubbia-Brandt, A. Roth, G. Mentha (Genève)
Objective: La mortalité liée aux résections hépatique chez des malades sélectionnés a été évaluée à
moins de 2%. Dans cette étude portant sur 606 hépatectomies électives réalisées consécutivement chez
61
des malades non sélectionnés (pathologies bénignes ou malignes, patients cirrhotiques, fibrose ou stéatose hépatique), nous avons analysé les facteurs de risque de morbidité et mortalité à partir d’une base
de données prospective.
Methods: Toutes les hépatectomies électives depuis le 01.01.1991 ont été inclues. La morbidité et la mortalité ont été classifiées selon une nomenclature standardisée (Clavien et al., Surgery 1992) modifiée. Les
données proviennent de la banque informatique genevoise des hépatectomies.
Results: 606 hépatectomies ont été effectuées entre le 01.01.1991 et le 16.07.2007. Aucune complication
n’a été observée pour 380 hépatectomies (63%). Dans 212 cas nous avons relevé une complication.
125 cas de complication mineure: 68 de degré I (ne menaçant pas la vie, n’impliquant pas d’autres médicaments que des antipyrétiques ou analgésiques), 57 de degré IIa (impliquant l’utilisation d’un médicament ou d’une transfusion). 62 cas de complications de degré modéré (IIb), impliquant une procédure
invasive. 22 cas de complications sévères: 16 ré-interventions chirurgicales (2.6%) (IIc) et 4 procédures
entraînant la perte d’un organe ou des séquelles (III). Il y a eu 5 décès (0.8%) (IV). Parmi les facteurs
corrélés à un taux plus élevé de complications, nous avons relevé la transfusion sanguine per-opératoire
(p<.000001), un score ASA > 3 (p=.0002), une résection de > 3 segments (p=.0001), l’indication pour
pathologie maligne (p=.00002). Il n’y avait pas plus de complications lors d’une hépatectomie itérative
que lors de la première (p=.65) et les patients de > 70 ans n’ont pas eu plus de complications que les
jeunes (p=.30).
Conclusion: L’hépatectomie élective, même majeure ou chez des patients cirrhotiques, est devenue une
procédure grevée d’un faible taux de mortalité. Une chirurgie sans transfusion est hautement corrélée
à l’absence de complications. Bien que les résections majeures pour cancer ainsi que les secondes et
même troisièmes hépatectomies chez un même patient soient devenues plus fréquentes, la morbidité
des hépatectomies n’a pas augmenté, cependant elle reste liée aux transfusions sanguines. En conséquence, toutes les mesures tendant à diminuer l’hémorragie per-opératoire doivent être entreprises.
55.2
Control of pelvic sepsis with preservation of intestinal continuity in rectal anastomotic dehiscence: a new
treatment modality using subatmospheric pressure and intraluminal meshed skin graft
Y. Borbély, D. Inderbitzin, C. Jost, D. Candinas, C. Seiler (Bern)
Objective: We present a novel, minimally invasive method where on one hand pelvic sepsis is controlled
and on the other hand massive anastomotic rectal insufficiency is treated. By transrectal application of
subatmospheric pressure devices, abscess cavities are resolved, intestinal integrity is restored and retraction of the proximal colon is avoided. To prevent scarring and stenotic obstruction, skin mesh graft is
transplanted from thigh into the neorectum bridging any mucosal defects.
Methods: We present the case of a 56year old caucasian male who was diagnosed with obstructing
rectal carcinoma 1-2 cm above the M.sphincter ani. After preoperative radiochemotherapy he underwent
low anterior resection and total mesorectal excision. Pullthrough, handsewn, coloanal anastomosis was
performed 5mm above the dentate line and for protection loop ileostomy was created. After an uneventful recovery, the patient returned on pod 24 with a soft abdomen, subfebrile temperature and elevated
CRP- and leucocyte levels. Abdominal CT scan revealed air in the lower pelvis and anastomotic leakage
was anticipated. In the O.R., flexible rectoscopy and anterograde colonoscopy showed a circumferential
anastomotic dehiscence of about 3.5cm and a huge abscess cavity. An Endo-SPONGE© (B. Braun Biosurgicals) was inserted transrectally and a vacuum of 100mmHg was applied. The Endo-SPONGE was
changed in an ambulatory setting every 5 to 7 days, always under endoscopic control. In between, two
systems were inserted, one in the abscess cavity, the other as splint to avoid retraction of the proximal
colon. After 6 weeks, clean conditions were met, there was however only minimal „epithelization“. To
prevent scarring and stenotic occlusion and accelerate the healing process in order to perform postoperative chemotherapy, skin mesh graft (1.5:1) was taken from the thigh, mounted on the endosponge
and placed in the endoanal region. 7 days later, the system was removed and flexible rectoscopy showed
almost complete engraftment of the skin mesh graft.
Results: Control endoscopies on a weekly basis were performed.
Conclusion: Anastomotic leakage after surgical resection of rectal cancer is one of the most significant
early complications, occurrence rates up to 23% are reported in the literature. There is a wide range of
treatment options, from Hartmanns procedure to CT-guided insertion of drainage. Healing takes time and
does often result in stenosis, strictures or persistent anal discharge due to fibrosis. Even more, stoma
closure cannot be performed in all patients. We describe a novel treating modality, in which intestinal lumen and length is conserved and abscess cavities are resolved using a vacuum-assisted wound closure
device acting as splint, applied transrectally. Thereby, abscess cavities are reached via the anastomotic
leakage. After conditioning the wound ground, mesh skin graft is applied for faster “epithelization” and
stenotic occlusion due to scarring is prevented.
55.3
Preoperative haemoglobin level is an independent factor associated with blood transfusion in patients
undergoing liver resection
R.E. Vandoni, A. Pelloni, P. Gertsch (Bellinzona)
Objective: Intra-operative blood transfusion has a negative impact on survival of patients with malignant
diseases and increases the morbidity in patients undergoing hepatectomy. Various factors, amongst
which coagulation parameters and characteristics of the liver structure, may influence intra-operative
blood loss. We analysed factors that may have influenced blood transfusion in patients undergoing liver
resection
Methods: In patients submitted to hepatectomies, we prospectively recorded the following data: age,
sex, indication for liver resection, administration of pre-operative chemotherapy, coagulation parameters,
preoperative haemoglobin level, blood loss during operation and during hepatic transection, cut surface
and weight of the resected liver, presence of hepatic fibrosis on histology, and immediate postoperative
haemoglobin level. The influence of these factors on blood transfusion was assessed in a uni- and multivariate analysis.
62
Results: During the period from June 1995 to December 2007, 176 consecutive patients (104 males),
were submitted to hepatectomies. Median age was 65 years (28-82 years). Malignancies were present
in 147 patients (64 colorectal metastases, 51 hepatocarcinomas, 21 cholangiocarcinomas, 7 non-colorectal metastases and 4 other malignancies). Sixty-one patients (35%) received blood transfusion
during hospital stay (median 3, range 0 – 22). Univariate analysis (Fisher exact test, ANOVA or logistic
fit where applicable) showed that age (p=0.03), cut surface (p=0.002) and weight of the resected liver
(p=0.0002), blood loss and preoperative haemoglobin level (both p<0.0001) were statistically significantly associated with blood transfusion. In the multivariate analysis (nominal logistic regression) only
blood loss (p<0.0001) and preoperative haemoglobin level (p=0.002) were statistically significant. Patients having received blood transfusion had a longer hospital stay (18 vs 14 days, p<0.0001). Lower preoperative haemoglobin level was associated with a longer hospital stay (p=0.01), but blood loss was not.
Conclusion: It is not unexpected that intra-operative blood loss was associated with blood transfusion.
Surprisingly, low preoperative haemoglobin level was an independent factor for administrating blood
transfusion and for longer hospital stay. Preoperative correction of haemoglobin level may reduce the
need for transfusion and also may lower hospital stay of patients undergoing hepatic resection.
55.4
Netzfixation bei der endoskopischen Inguinalhernienoperation: Problem bei grossen direkten Hernien?
F. Grieder, H. Gelpke, M. Decurtins (Winterthur)
Objective: Insbesondere bei beidseitigen Hernien und Rezidivhernien hat sich in den letzten Jahren die
extraperitoneale endoskopische Hernienversorgung als gutes Operationsverfahren erwiesen. Zur allfälligen Fixation des Netzes sind auf dem Markt verschiedene Produkte erhältlich. Spiraltacker erlauben eine
sichere Fixation im Bereiche des Lig. cooperi. Lateralseits muss jedoch wegen der Gefahr chronischer
Schmerzen auf eine zusätzliche Fixation verzichtet werden. Dies ist bei der Fibrinverklebung möglich, so
dass dadurch allenfalls Netzdislokationen und laterale Rezidive vermieden werden können. Der Nachteil
an der Fibrinverklebung ist die fehlende Möglichkeit einer Raffung der Transversalisfaszie bei grossen direkten Hernien und die dadurch entstehende Gefahr einer Pseudohernienbildung (Hämatom/Serom). In
solchen Fällen hat sich bei uns die Faszienraffung mittels Endoloop/Roederschlinge bewährt.
Methods: Im Jahre 2007 haben wir an unserem Spital 473 Patienten mit 591 Inguinal- oder Femoralhernien operiert. Eine extraperitoneale endoskopische Operationstechnik wurde bei 69 Patienten angewandt (12 Patienten mit einseitigen und 57 mit beidseitigen Hernien). Bei 30 Patienten wurde das Netz
mit Fibrinkleber (1ml/Seite) fixiert. Hierbei erfolgte auch lateralseits eine Verklebung des Netzes mit der
Bauchdecke und dem M.psoas. Bei sechs Patienten mit grossen direkten Hernien wurde zusätzlich eine
Raffung der Transversalisplastik mittels Endoloop (PDS 2-0) durchgeführt.
Results: Alle Patienten mit Raffung der Transversalisplastik mittels Endoloop sowie Netzfixation mittels
Fibrinkleber zeigten einen problemlosen postoperativen Verlauf. Der Spitalaustritt war am ersten oder
zweiten postoperativen Tag. Keiner der Patienten erlitt ein Hämatom/Serom postoperativ. Alle Patienten
konnten rasch ihre normale Arbeit wieder aufnehmen und waren einen Monat postoperativ mit der Operation zufrieden.
Conclusion: Bei der Verwendung eines Fibrinklebers zur Netzfixation hat sich bei grossen direkten Inguinalhernien die Raffung der Transversalisfaszie mittels Endoloop als gute Alternative zur Fixation mittels
Spiraltacker erwiesen.
55.5
Transperitoneal minimally invasive necrosectomy for infected necrotizing pancreatitis
P. Bucher, F. Pugin, Ph. Morel (Genève)
Objective: Infected necrotizing pancreatitis is a serious and therapeutically challenging complication. Percutaneous drainage of infected pancreatic necrosis is often unsuccessful. Alternatively, open necrosectomies are associated with high morbidity. Recently, minimally invasive necrosectomy techniques have
been tried with satisfying results; however, they have all been used only for retroperitoneal approach. While retroperitoneal approach is satisfactory for left sided pancreatic necrosectomy it is difficult to applied
to pancreatic head necrosis. We here described for the first time a single port endoscopic transperitoneal
approach for head necrosectomy.
Methods: We report the first experience with transperitoneal single access endoscopic necrosectomy for
infected pancreatic head necrosis. This technique was adapted from our technique of minimally invasive
retroperitoneal endoscopic necrosectomy approach. This technique was to a 28 years old patient with
biliairy necrotizing pancreatitis due to absence of control of septic head necrosis through radiological
drainage. Single port endoscopic necrosectomy was performed through placement of a 12mm troccar
transperitoneally along drain tract directly into pancreatic necrosis cavity.
Results: Two sessions of transperitoneal endoscopic necrosectomy were needed to achieve complete
clearing of the infected necrosis. No per-operative complications were recorded with a median operative
time of 48 (+ 10) minutes. No surgical post-operative complications were recorded. Patient did not needed additional radiological drainage or surgical treatment except a laparoscopic cholecystectomy after
endoscopic necrosectomy.
Conclusion: Minimally invasive endoscopic necrosectomy is highly effective for pancreatic necrosectomy
in infected necrotizing pancreatitis even through a transperitoneal apporach. In this preliminary experience this approach has appear to be a safe and successful.
55.6
Islet autotransplantation after extended pancreatectomy for benign tumors of the pancreas, a step toward living donors?
F. Ris1, N. Niclauss1, Ph. Morel1, S. Demuylder-Mischler1, J. Oberholzer2, L. Bühler1, D. Bosco1, T. Berney1
(1Genève, 2Chicago/US)
Objective: Islet autotransplantation has proven successful in the prevention of surgical diabetes after pan-
creas resection for chronic pancreatitis (CP), with insulin independence rates of 50% at 1 year. We report
our experience with islet autotransplantation after extensive pancreatectomy for the resection of benign
tumors of the pancreas.
Methods: Between January 1992 and December 2007, we followed prospectively all patients who underwent extensive left pancreatectomy for benign lesions located left to the neck of the pancreas. Tumors
were separated from the specimen and sent for extemporaneous pathological examination. After unequivocal diagnosis of benignity, the rest of the specimen was processed according to the Ricordi method and
unpurified pancreatic digest was infused into the portal vein. Isolation results were compared with those
of autologous donors with CP and brain-dead donors (BDD) over the same period.
Results: 10 patients had autotransplantation for benign tumors, 1 for abdominal trauma and 10 for CP
during this 15 years period. Tumors were 7 cystadenomas and 3 insulinomas. Mean islet yields were
250704 IEQ vs 110290 in CP (p=0.03) and 256522 in BDD (p=0.89) or 6005 IEQ/gram of tissue vs
1457 in CP (p=0.01) and 2798 in BDD (p<0.01), resulting in transplantation of 3874 IEQ/kg body weight
vs 2196 in CP (p=0.10). Median follow-up for benign disease was 101 months, one patient died from
unrelated causes after a 142-month follow-up. After a 6-year median follow-up, all patients have positive
basal and glucagon-stimulated C-peptide levels and 9/10 patients are insulin-free.
Conclusion: Pancreatic tissue resected for benign tumors is more likely to result in good islet yields, as
compared to CP or BDD tissue, and thus in insulin independence after autotransplantation. These results
may contribute to provide some rationale for the similar situation of live donors of segmental pancreatic
grafts for islet allotransplantation.
55.7
Wertigkeit der minimal-invasiven, fokussierten Parathyreoidektomie bei gleichzeitiger Strumapathologie
O. Heizmann, R. Schmid, C.T. Viehl, D. Oertli (Basel)
Objective: Neue Techniken der Adenomlokalisation und die Möglichkeit der intraoperativen Messung
des intakten Parathhormons (iPTH) führten zur Einführung der fokussierten minimal invasiven Parathyreoidektomie (MIP). Bei dieser Operationstechnik ist das Risiko, die gleichzeitig vorliegende und behandlungsbedürftige Schilddrüsenpathologie zu übersehen, nicht unerheblich. Das Ziel dieser Studie ist die
Evaluation der Wertigkeit der fokussierten MIP unter Einbezug der gleichzeitigen Schilddrüsenpathologie
und deren Einfluss auf präoperative Abklärungen.
Methods: Dreißig konsekutive Patienten mit pHPT (mittleres Alter 65 Jahre, 17 Frauen, 13 Männer) wurden in die prospektive klinische Studie eingeschlossen. Präoperative Lokalisationsdiagnostik wurde routinemäßig mittels Sonographie und/oder Tc99m-Sestamibi Szintigraphie durchgeführt.
Results: Bei 10 Patienten(33%) lag gleichzeitig eine operationsbedürftige Schilddrüsenpathologie vor
und bei 2 (7%) erfolgte auf Grund negativer Lokalisationsdiagnostik eine bilaterale Halsexploration.
Die fokussierte MIP wurde bei 18 (60%) Patienten durchgeführt. Die Konversion zur konventionellen
Halsexploration betrug 6% (1/18). Die Sensitivität der Sonographie lag bei 78,8% und der Tc99m-Sestamibi Szintigraphie bei 83,3%. Die Accuracy bei diesen präoperativen bildgebenden Methoden lag bei
78,8% respektive bei 83,3%.Bei Patienten ohne gleichzeitiger Schilddrüsenpathologie lag die Sensitivität
der Sonographie bei 88,8% und der Tc99m-Sestamibi Szintigraphie bei 94,4%. Während der mittleren
Nachbeobachtungszeit von 35 Monaten entwickelte keiner der Patienten ein Rezidiv, entsprechend einer
Heilungsrate von 100%.
Conclusion: Eine Schilddrüsenpathologie bei Patienten mit pHPT liegt in unserer Region häufig vor. Die
Sonographie und die Tc99m-Sestamibi Szintigraphie haben bei Patienten ohne gleichzeitig vorliegender
Schilddrüsenpathologie eine sehr hohe Lokalisationsquote. MIP in Kombination mit iPTH-monitoring zeigt
in dieser Patientengruppe eine sehr hohe Erfolgsquote und soll Methode der Wahl sein.
55.8
Perineal Stapled Prolapse resection (PSP): a new procedure for external rectal prolapse
L. Marti1, R. Scherrer2, K. Wolff1, F. Hetzer1 (1St. Gallen, 2Berlin/DE)
Objective: A perineal approach for the treatment of rectal prolapse is ideal for frail patients. Internal rectal
prolapse has been successfully treated with transanal resection using the Contour® TranstarTM. This technique has been modified to the perineal stapled prolapse resection (PSP), a new procedure for external
rectal prolapse.
Methods: Patients unsuited to transabdominal treatment were recruited prospectively for PSP in two colorectal centres. Feasibility, complications and reinterventions were assessed.
Results: In 14 of 15 patients, PSP was performed without complications with a median operating time of
33 (range: 22-52) minutes. One procedure was changed to an Altemeier due to a staple line disruption.
Two patients required reintervention due to postoperative haemorrhage. No other severe complications
occurred. At follow-up, all patients were well and showed no early recurrence of prolapse.
Conclusion: PSP is a safe and easy surgery to perform for rectal prolapse. Functional results and the longterm recurrence rate must be further investigated.
55.9
Single port laparoscopic McBurney approach for acute appendicitis
P. Bucher, M. Gonzalez, F. Pugin, N.C. Buchs, F. Ris, Ph. Morel (Genève)
Objective: Exploration of suspected appendicitis through laparoscopy offers the advantage to perform a
complete abdominal exploration compare to typical Mc Burney incision. For this reason laparoscopic is
becoming the gold standard for suspected acute appendicitis; however, its cost is higher and it conventionally implicates three skin incision. Study aim was to evaluate the feasibility of single port laparoscopic Mc
Burney approach for acute appendicitis and cost effectiveness in terms of operative time.
Methods: Preliminary experience using single working port (12mm troccars) laparoscopic Mc Burney in
8 patients suspected of having acute appendicitis. Parallele use of 5mm optic and either 5mm forceps or
5mm washing/suction device inside the working port were performed. After appendix mobilisation if was
exposed through skin incision for appendectomy. Median patient age was 27 years and median BMI 22.
Results: In all patients the diagnosis of acute appendicitis was confirmed per-operatively, with 3 retroceacal acute appendicitis. Median operative time was 32 (24-45) min. Complete intra-peritoneal exploration
was feasible in all patients. Abdominal lavage with (1-3L of saline solution) was performed in all patients.
Conversion to a 2 troccars laparoscopic appendectomy was needed in one case due to difficulties in
appendix mobilisation. No per- or post-operative complications were recorded.
Conclusion: Single port laparoscopic McBurney is easily feasible, allow complete exploration and lavage
of the abdominal cavity with striking reduction in the number of abdominal scar compare to standard
laparoscopic appendectomy.
55.10
Results of 110 solitary islet transplantations in 66 type 1 diabetic patients in the swiss-french GRAGIL
consortium
N. Niclauss1, F. Ris1, A. Wojtusciszyn2, L. Kessler3, L. Badet4, A. Penfornis5, F. Bayle6, C. Thivolet4, D. Bosco1,
Ph. Morel1, P.Y. Benhamou6, T. Berney1 (1Genève, 2Montpellier/FR, 3Strasbourg/FR, 4Lyon/FR, 5Besançon/
FR, 6Grenoble/FR)
Objective: GRAGIL is a Swiss-French collaborative multicenter network active since 1999. In this study, we
review the results of solitary islet grafts and analyze their outcome with respect to immunosuppression,
indication and shipment of islets.
Methods: Hundred and ten islet transplants were performed in 66 patients with type 1 diabetes, in islet
transplant alone (ITA; N=26) and islet-after-kidney (IAK; N=40) procedures. The groups shown on Table
1 were analyzed.
Results: Results are shown in Table 2. The results of Group 0 are typical of the “pre-Edmonton” era. Dis
appointing results of Group 1 seem to result from the IS regimen. Results from Groups 2-5 show that
similar outcomes were achieved in ITA and IAK, regardless of shipment of islets, when the Edmonton IS
protocol was used.
Conclusion: This analysis emphasizes the relevance of multicenter networks such as the GRAGIL group
with centralized production of islet preparations, and shows that a good outcome of islet Tx can be achieved in the IAK indication.
Group 0
1
2
3
4
5
Indication IAK IAK IAK ITA ITA IAK IS CsA/MMF steroids basiliximab CsA/everolimus/basiliximab Tacrolimus/sirolimus/daclizumab Tacrolimus/sirolimus daclizumab Tacrolimus/sirolimus daclizumab Tacrolimus/sirolimus daclizumab shipment Yes/No Yes No No Yes Yes N (Pat/Tx) 12/12 9/16 9/17 8/20 19/28 11/15 Group Primary nonfunction Insulin independence > Insulin independence 1 month
at 1 year * 0
8% (1/12) 17% 17% 1
11% (1/9) 67% 11% 2
0
100% 78% 3
0
63% 63% 4
0
83% ** 50% ** 5
0
88% 50% Years
1999-2001
2001-2002
2001-2005
2002-2006
2003-2007
2004-2007
Graft function
at 1 year
(C-peptide) *
50%
50%
89%
100%
93%
100%
* or at latest follow-up for patients who haven’t reached 1 year ** only patients with completed transplants
(2 infusions) are considered
55.11
Parathyroid gland localisation by fine needle aspiration – a diagnostic tool in complex cases of hyperparathyreoidism
H. Gelpke1, S. Breitenstein2, F. Grieder1, M. Decurtins1 (1Winterthur, 2Zürich)
Objective: Because of their potentially wide distribution, the localisation of residual parathyroid glands
can be a severe problem in cases of recurrent or persistent hyperparathyroidism. The aim of these case
presentations is to emphasise the relevance of ultrasonographically guided fine needle aspiration (FNA)
to test parathyroid hormone for localisation of parathyroid glands preoperatively in complex situations.
Methods: Presentation of two cases.
Results: A 49 year old male, hemodialysed for 13 years was operated for secondary hyperparathyroidism. Three enlarged parathyroid glands were removed. The right caudal gland could not be found and
hyperparathyroidism persisted. The fourth gland was then apparently located szinthigraphically in projection to the right lower lobe of the thyroid gland. Following the right-sided hemithyroidectomy, parathyroid
hormone level did not decrease and a total thyroidectomy was carried out. Because of the persistence of
the hyperparathyroidism, radiographic venus sampling, CT- and MRI-Scan were applied but initially not
conclusive. The only irregularity was a 2cm node between the right parotid and submandibular glands
suspected to be a lymph node. Ultrasonic guided FNA of this lesion showed a clear elevation of parathyroid hormone levels and clear cells on cytology. After surgical removal of this displaced parathyroid gland
together with transplantation of 100mg in the left forearm, hyperparathyroidism disappeared. A 67 year
old blind female showed hypercalcemia at a routine control. Further investigation diagnosed hyperparathyroidism. Szinitigraphia showed a spot on the right side in projection of the thyroid. Sonography located
a node in the right thyroid. FNA surprisingly showed a parathyroid gland within the thyroid gland, which
could be treated by hemithyroidectomy. Reviewing the literature the preoperative use of ultrasonographic
guided FNA to localize parathyroid glands is described only few. In these descriptions it is regarded as a
63
minimally invasive, highly specific localisation test.
Conclusion: The localisation of parathyroid gland can be a severe diagnostic problem. As demonstrated,
ultrasonographically guided FNA to test parathyroid hormone levels is a helpful diagnostic option to differentiate preoperatively suspected lesions in difficult cases of parathyroid gland displacements.
55.14
55.12
Objective: Postoperative ileus is a common condition after abdominal surgery. Many prokinetic drugs
have been evaluated including osmotic laxatives. The data on colon-stimulating laxatives is scarce. This
prospective, randomized, double-blind trial investigates the effect of the colon-stimulating laxative bisacodyl on postoperative ileus in elective colorectal resections.
Methods: Between November 2004 and February 2007, 200 consecutive patients were randomly assigned to receive either bisacodyl or placebo. Primary endpoint was time to gastrointestinal recovery (mean
time to first flatus passed, first defecation and first solid food tolerated; GI-3). Secondary endpoints were
incidence and duration of nasogastric tube reinsertion, incidence of vomiting, length of hospital stay and
visual analogue scores for pain, cramps and nausea.
Results: 169 patients were analyzed, 31 patients discontinued the study. Groups were comparable in
baseline demographics. Time to GI-3 was significantly shorter in the bisacodyl group (3.0 versus 3.7
days, P=0.007). Of the single parameters defining GI-3, there was a one day difference in time to defaecation in favor to the bisacodyl group (3.0 versus 4.0 days, P=0.001), whereas no significant difference in
time to first flatus or tolerance of solid food was seen. No significant difference in the secondary endpoints
was seen. Morbidity and mortality did not differ between groups.
Conclusion: Bisacodyl accelerated gastrointestinal recovery and might be considered as part of multimodal recovery programs after colorectal surgery.
Zirkuläres Polypropylenenetz – ideal zur Netzverstärkung am Hiatus oesophagei?
B.P. Müller-Stich1, A. Mehrabi1, H.G. Kenngott1, F. Nickel1, M. Reiter1, H. Funouni1, Z. Mood1, G. Kuttymuratow1, G.R. Linke2, J. Köninger1, C.N. Gutt1 (1Heidelberg/DE, 2St. Gallen)
Objective: Die Notwendigkeit einer Netzverstärkung in der Hiatushernien- und Antirefluxchirurgie wird
zurzeit intensiv diskutiert. Einerseits haben randomisiert kontrollierte Studien gezeigt, dass mittels Netzverstärkung die Rezidivrate gesenkt werden kann, andererseits besteht im Zusammenhang mit der
Netzverstärkung am Hiatus die Furcht vor netzbedingten Komplikationen wie Netzmigrationen, Ösophagusstenosen, intestinale Erosionen und Adhäsionen. Bisher wurden verschiedenste Netzmaterialien und
-Formen für die Verwendung am Hiatus vorgeschlagen. Experimentelle Untersuchungen dazu liegen
nicht vor. Aus diesem Grund evaluierten wir den von uns verwendeten Netztyp – ein zirkuläres Polypropylenenetz – im Schweinemodell.
Methods: Ein standardisiertes 55 x 55 mm grosses Polypropylenenetz (Surgipro™) mit einer 16.5 mm
im Durchmesser messenden exzentrischen Aussparung für den Ösophagus (berechnete Netzfläche 281
mm2, berechnete Lochfläche 21 mm2) wurde in 9 Deutsche Landschweine mit einem Gewicht von 23
± 1.5 kg implantiert und mit Fibrinkleber (Beriplast™) fixiert. Nach 6 Wochen erfolgte die Explantation
und Vermessung der Netze. Zur Quantifizierung der Migrationstendenz wurde bei 3, 6, 9 und 12 Uhr die
Distanz zwischen Netzkante und muskulärem Hiatusrand gemessen. Zusätzlich wurde auf Erosionen
und Adhäsionen geachtet.
Results: Bis zum Zeitpunkt der Explantation schrumpfte die Netzfläche auf 204 ± 18 (183 – 24) mm2;
(p < 0.001). Demgegenüber bestand ein Trend zur Vergrösserung der Aussparung für den Ösophagus
auf 24 ± 4 (18 – 29) mm2; (p = 0.108). In keinem Fall und an keiner Stelle überlappte die Netzkante den
muskulären Hiatusrand. Der entsprechende Rückzug der Netzkante vom muskulären Hiatusrand bei 3,
6, 9 und 12 Uhr betrug 7 ± 2 (5 – 10), 5 ± 2 (3 – 8), 4 ± 1 (3 – 7) und 1 ± 1 (0 – 4). Es kam zu keinerlei
Erosionen. Die Netze waren vollständig mit Adhäsionen bedeckt, wobei die Adhäsionen in jedem Tier zu
einer dorsalen Fixation des Ösophagus bzw. der Cardia im Sinne einer intraabdominellen Verankerung
führten.
Conclusion: Ein zirkuläres Polypropylenenetz scheint ideal geeignet für die Netzverstärkung am Hiatus
oesophagei. Es weist weder eine Stenosierungs- noch eine Migrationstendenz auf. Mögliche Erklärungen
dafür sind, dass die Netzkontraktion tendenziell zu einer Erweiterung der Netzaussparung für den Ösophagus führt und dass eine rasche Gewebeintegration in Kombination mit einer Schienung durch den
Ösophagus die Positionsstabilität gewährleistet. Die Adhäsionstendenz sichert potentiell die dauerhafte
intraabdominelle Fixation des ösophagogastralen Überganges im Sinne einer zusätzlichen Rezidivprophylaxe.
55.13
Chirurgie viscérale chez la femme enceinte: expérience genevoise et revue des critères actuels
D. Azagury, F. Ris, A. Andrey, Ph. Morel (Genève)
Objective: La prise en charge des pathologies non obstétricales chez la femme enceinte reste problématique. Nous avons revu notre expérience sur 6 ans afin d’évaluer les pathologies les plus fréquentes et
leur prise en charge.
Methods: Revue rétrospective entre janvier 2002 et décembre 2007 recensant les interventions chirurgicales effectuées en cours de grossesse, leur prise en charge, ainsi que la morbidité maternelle et fœtale.
Results: 28 hospitalisations et autant d‘interventions ont eu lieu chez 24 patientes enceintes. L’âge moyen
était de 28 ans et 8 mois et la durée moyenne de séjour de 6,3 jours. Il y eût 12 interventions pour suspicion d’appendicite (3 laparotomies), dont 3 explorations non contributives. En moyenne, les grossesses
étaient à 18,1 semaines, et le temps entre l’arrivée à l’hôpital et l’intervention de 18,4h. Neuf cholécystectomies ont été réalisées, 3 électives (deux lithiases symptomatiques et un status post pancréatite) et 6
en urgence (5 cholécystites et un status post migration cholédocienne). L’âge de grossesse moyen était
de 16,3 semaines. Une ileo-caecetomie pour maladie de Crohn perforée, une laparotomie exploratrice
pour section de bride, une révision des voies biliaires et 4 interventions chez la patiente polytraumatisée
ont en outre été réalisées. Une patiente a nécessité un curetage utérin pour mort fœtale in utero à 14
semaines (polytrauma), une interruption volontaire de grossesse a été effectuée en raison d‘une grossesse non désirée. Une patiente a eu une menace d‘accouchement prématuré 17 semaines après son
appendicectomie. Toutes les autres patientes ont bénéficié d’un contrôle pré et post opératoire du fœtus,
sans aucune anomalie détectée. Aucun médicament tocolytique n’a été nécessaire. Toutes les autres
patientes suivies ont accouché à terme entre 34 et 42 semaines de gestation, à l’exception de 4 n‘ayant
pas encore accouché.
Conclusion: Les résultats de notre série corroborent ceux de la littérature actuelle. Une prise en charge
agressive de ces pathologies est nécessaire afin de garantir une survie de la mère et de l’enfant à cours
et à long terme. En cas d’appendicite une laparoscopie peut être effectuée quelque soit la période de
gestation.
64
Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery. A prospective, randomized trial
U. Zingg1, D. Miskovic2, I. Pasternak3, P. Meyer3, C.T. Hamel1, U. Metzger3 (1Basel, 2Frimley, Camberley/UK,
3
Zürich)
55.15
Immunmodulierende Ergänzungsnahrung: hohe Compliance dank mündlicher und schriftlicher Instruktion und Gratis-Abgabe
B.M. Galliker, V. Schreiber, J.A. Wydler, R. Schlumpf (Aarau)
Objective: Präoperativ eingenommene immunmodulierende Ergänzungsnahrung mit Zusätzen wie
omega-3-Fettsäuren, RNA und Argingin bewirkt durch Minimierung der Infekte und Komplikationen eine
Reduktion der Hospitalisationstage. Um dieses Ziel zu erreichen muss nach gegenwärtigem Wissensstand eine solche Ergänzungsnahrung über mehrere Tage dreimal täglich eingenommen werden. Seit
August 2006 wird Oral impact® (OI) vom Spital an Patienten vor grossem elektiven viszeralchirurgischem
Eingriff gratis abgegeben. Gute Resultate werden durch korrekte Einnahme erreicht. Das Ziel war eine gute
Einnahmequalität zu erreichen.
Methods: Das Spital hat die Einkaufskosten von OI übernommen. OI wird im Rahmen einer Sprechstunde
abgegeben. Die Art der Einnahme wurde in den ersten 10 Monaten mündlich erklärt. Seit 7 Monaten wird
den Patienten zusätzlich eine schriftliche Erklärung mitgegeben. Bei Spitaleintritt haben wir bei sämtlichen
Patienten eine kurze Befragung durchgeführt. Dabei wollten wir wissen ob OI korrekt eingenommen wurde, und ob das Produkt gut vertragen wurde. Von August 2006 bis Ende 2007 wurde OI an insgesamt
173 Patienten abgegeben.
Results: Von den 173 Patienten konnten wir 170 befragen. Zwei Personen verweigerten die Auskunft
und eine demente Patientin konnte keine Auskunft geben. Lediglich zwei Personen haben OI nicht eingenommen. In den ersten 10 Monaten haben 100 Patienten OI bekommen. Davon haben 60 das Produkt
korrekt eingenommen, das heisst die letzten fünf präoperativen Tage dreimal täglich. Danach führten wir
eine schriftliche Einnahmebeschreibung ein. Seither stieg die korrekte Einnahme auf 77% an. Gründe für
falsche Einnahme waren: Erklärungen nicht verstanden, Einnahme vergessen, Operationstermin weniger
als 5 Tage nach der Sprechstunde, sowie Verschiebung der Operation. Nur sieben Personen (4,2%) haben die Einnahme abgebrochen, vor allem weil das Produkt gastrointestinale Beschwerden verursachte.
58% beurteilten den Geschmack als gut oder sehr gut und nur 6% fanden den Geschmack schlecht. 75%
beurteilten die Menge als gerade richtig, 68% gaben ein Völle- oder Sättigungsgefühl nach der Einnahme
an. Die Hälfte hat die Essensmenge während der Einnahme nicht verändert. 35 Patienten (21%) gaben
Unannehmlichkeiten an: Diarrhoe, Bauchkrämpfe und bei Diabetikern Anstieg des Blutzuckers. 95% der
Patienten würden OI wieder Einnehmen, 59% auch gegen Zahlung von 300CHF.
Conclusion: Damit die Ergänzungsnahrung korrekt eingenommen wird, ist eine mündliche und schriftliche Erklärung zwingend notwendig. Damit erreichten wir eine hohe Compliance obwohl 21% über Unannehmlichkeiten berichteten. Bei Abgabe durch das Spital ist eine deutlich höhere Einnahmebereitschaft
zu erreichen als bei Selbstzahlung, wo 41% nicht bereit wären das Produkt einzunehmen.
55.16
Prognostic influence of immunohistochemically detected lymph node metastases and histological subtype in esophageal cancer patients
U. Zingg1, M. Montani2, M. Busch3, U. Metzger2, P. Went2, D. Oertli1 (1Basel, 2Zürich, 3Bülach)
Objective: A number of studies have assessed the prognostic value of immunohistochemically detected
metastases in haematoxylin/eosin (H/E) stained negative lymph nodes with inconsistent results. The
evidence on differences of micrometastasis frequency and prognostic value between the histological
subtypes of esophageal cancer is scarce. The present study is addressing this issue.
Methods: Between 1990 and 2006, 224 patients with esophageal cancer were treated at two surgical
institutions. 86 patients (38%) with histologically complete resection and N0 status by standard H/E staining were included into this study. Multiple step sectioning of each paraffin embedded lymph node using
3µm thick serial sections was performed. Additional to H&E stains, immunostains with Lu-5 (Cytokeratin)
were done. All slides were independently evaluated by two surgical pathologists. Intra-nodal tumor cell
infiltrates were classified as follows: micrometastasis (MM: diameter between 0.2mm and 2mm), single
tumor cells (STC: less than 0.2mm). Cytokeratin positive material devoid of any evidence of vital nuclei
was classified as “avital cytokeratin positive material” (ACPM). Overall survival and disease free interval
was calculated using Kaplan-Meier. To determine the influence of different variables on outcome, a Cox
regression analysis was performed.
Results: 1204 lymph nodes from 32 (37%) squamous cell cancers and 54 (63%) adenocarcinomas
were examined. MM were found in 12 (1%) nodes of 7 (8%) patients, STC in 38 (3%) nodes of 17 (20%)
patients and ACPM in 17 (1.4%) nodes of 7 (8%) patients. Concerning localisation, 5 out of 7 MM’s were
located in the parenchyma whereas 15 out of 17 STC primarily in the peripheral sinus. There was no
significant difference in frequency of MM between squamous cell and adenocarcinoma (11.1% vs. 3.1%,
p=0.247), whereas STC occurred significantly more often in adenocarcinoma (27.7% vs. 6.3%, p=0.023).
Median follow-up of surviving patients was 47.4 months (range 14-159 months). Overall and disease
free survivals after 2 and 5 years were 74.1% and 79.1%; 58.9% and 69.7%, respectively. Although no
statistical differences in postoperative survivals were found, IHC negative patients showed a clear trend
towards higher survival rates. After differentiating into the histological subtypes, overall and disease free
survivals were significantly better (p=0.017 and p=0.006, respectively) in IHC negative patients with
squamous cell carcinoma, whereas no difference was found in adenocarcinoma. Multivariate regression
analysis showed no significant factor influencing overall survival in this nodal negative collective. However, significant factors influencing disease free interval were identified: pre-treatment (HR 3.3 [95% CI 1.29.1], p=0.020); MM (HR 5.3 [95% CI 1.4-19.7], p=0.012); UICC stage II vs. 0/I (HR 2.2 [95% CI 1.1-4.4],
p=0.032); adenocarcinoma (HR 0.3 [95% CI 0.1-0.9], p=0.028).
Conclusion: Squamous cell and adenocarcinoma showed significant differences in frequency of IHC
detected tumor cells. In squamous cell cancer but not in adenocarcinoma the detection of tumor cells
was associated with reduced postoperative survival. The histological subtype in esophageal cancer may
play a more important role than currently thought and might represent different clinical entities.
55.17
Does the «Estimation of Physiologic Ability and Surgical Stress» (E-PASS)-score enable surgeons to predict patients with bad outcome following esophageal resection for cancer?
R. Kam, M. Wagner, G. Krämer, D. Inderbitzin, C. Seiler, D. Candinas (Bern)
Objective: The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was designed on the
premise that the balance between the patient‘s physiologic reserve capacity and the surgical stress may
determine postoperative morbidity and mortality. Several studies have evaluated the effectiveness of the
E-PASS score for various surgical settings. The purpose of this study was to evaluate its usefulness in
estimating outcome after elective esophageal resection for caner.
Methods: Relevant data of all patients undergoing oesophageal surgery at our institution are entered in a
prospectively recorded statistical database. E-PASS data items were computed retrospectively and patients were divided into severity groups according to the E-PASS scoring. Operative morbidity and mortality
rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS.
Results: Between January 2002 and October 2007 a total of 93 consecutive patients underwent resection of esophageal cancer. 41 patients underwent transhiatal resection (44%), 15 transthoracic esophagectomy (16%) and 37 distal resections (40%). The observed and predicted overall mortality rates were
3.2% and 5.7%, mean CRS in the groups of patients who survived and died were identical (0.62 vs 0.88;
p = 0.20) but PRS showed a tendency to differ in the patient group who died (0.57 vs 0.89m p = 0.08).
Cumulative and predictive morbidity rates were 67% and 35%, SSS and CRS between patients with and
without complications differed significantly (mean SSS: 0. 0.45 vs 0.36, p = 0.047; mean CRS: 0.66 vs
0.48, p = 0.018;) but not PRS.
Conclusion: The E-PASS scoring system appears to be useful to compare and analyze postoperative
morbidity and mortality in patients undergoing elective esophageal resection for cancer. However, both
predicted mortality and morbidity rates were underpredicted. Thus, further refinements may be warranted
in order to determine patients at high risk who may profit from alternate treatment options.
Cardiac Surgery
58
58.1
A new mouse model of acute aortic dissection type A in Marfan syndrome
P. Matt1, J. Habashi2, J. Black2, T.P. Carrel3, D. Huso2, H.C. Dietz2 (1Basel, 2Baltimore/US, 3Bern)
Objective: Acute Aortic Dissection Type A is the main cause of death in patients with Marfan Syndrome
(MFS). We developed a procedure to surgically induce an acute aortic dissection type A in a mouse model
of MFS.
Methods: Ten fibrillin-1 deficient (Fbn1C1039G/+) and ten wild-type mice at 8 months of age were intubated, ventilated and the aorta exposed via a hemisternotomy. We hypothesized that an aortic dissection
type A could be induced in fibrillin-1 deficient or wild-type mice by either injecting autologous blood in the
aortic wall or by performing a clamp injury. Autologous blood was collected before and after induction of
the aortic lesion from the right femoral vein. The mice were sacrificed 30 minutes after aortic surgery.
Results: Transthoracic echocardiography of the aortic root performed prior to surgery showed significantly larger diameters in Fbn1C1039G/+ mice compared to the wild-type (p<0.0001). Aortic clamp
injury compared to injection of autologous blood led in Fbn1C1039G/+ and wild-type mice to a highly
reproducible visible aortic wall hematoma, and large intimal tears. In contrast, injection of autologous
blood into the aortic wall was difficult and led to less reproducible wall hematoma and small intimal
tears. After aortic clamp injury hematoxylin-eosin stained histological sections revealed a dissection of
the medial layer in all Fbn1C1039G/+ mice but not in wild-type mice (p<0.001). Wild-types showed only
transmural wall lesions. Aortic dissections in Fbn1C1039G/+ mice were limited to the ascending aorta.
Elastin-stained histological sections revealed a significantly higher elastic fiber fragmentation and disarray in Fbn1C1039G/+ aortas compared to wild-type mice (p<0.001). All mice survived 30 minutes after
inducing the aortic lesion.
Conclusion: We present a highly reproducible and in the short-term non-lethal mouse model of a surgically induced acute aortic dissection type A in MFS. This model may provide new insights into this life-threatening disease, which may lead to novel diagnostic and therapeutic strategies.
58.2
Trans-apical aortic valve implantation training for future cardiac surgeons
M. Vergnat, B. Perrin, D. Delay, L.K. von Segesser (Lausanne)
Objective: development of a training model for aortic stent valve trans-apical implantation, with physiological haemodynamics.
Methods: our in-vitro model is based on a cardiovascular simulator with a double-valved left ventricle
chamber connected to a resistance-adjustable compliant vascular loop. Ventricular and aortic pressure
(piezoelectric sensor), flow rates (ultrasound sensor) are monitored continuously (sampling rate : 2000
Hz). Systolic and diastolic aortic pressure, as well as compliance, are adjusted by vascular loop clamps.
Left ventricle is connected with a piston, computer-controlled volumetric pump, with adjustable stroke
volume and duration. Versatility of the system allows for a large panel of physiological / pathological
conditions, with control of dP/dt ratio. The valve simulating system was prepared as follows : a stentless
porcine aortic bioprothesis (Cryolife International, O‘Brien®, Atlanta, GA, USA) has been mounted on a
silicon annulus, in a silicon tube, simulating left ventricular outflow tract and aortic root; sealed port access to the ventricle has been created to simulate trans-apical aortic valve access. Test fluid used was
saline (14 l), heated up to 37°C with a heat exchanger. Pressure, heart and flow rates, stroke volume,
systolic duration have been set to mimic low cardiac output in an elderly woman, respectively 120 mmHg
systolic, 85 mmHg diastolic, 60 beats/min, 2.8 l/min, 66.5 ml, 35 % of cycle. Balloon expandable stent
valve delivery was simulated.
Results: simulated stepwise implantation of balloon expandable stent valve implantation results in systolic ventricular pressure increase, from 126 to 830 +/- 76 mmHg, systemic mean pressure drop, from
110 to 44 +/- 24 mmHg, and left ventricular outflow obstruction with mean trans-valvular gradient of 366
+/- 202 mmHg and output collapse 0.71 +/- 0.37 l/min (before complete obstruction). Ventriculo-aortic
migration forces were measured : 1.08 +/- 0.03 N with 5cc, 0,5B inflated balloon, 3.02+/-0.31 N (10cc,
1B), 10.82+/-0.08 N (15cc, 3B), 17.38 +/- 1.1 N (17.5cc, 4B). Water loss, with high pressure through portaccess introducers connections, are evaluated to 60cc.
Conclusion: first in vitro model for trans-apical aortic stent valve replacement is proposed. The new wet
simulator developed provide realistic haemodynamic/device relationship for stent valve implantation and
offers surgical training on working heart, with rational conditions.
58.3
Aortic cross clamping in surgery of acute type A aortic dissection: Does it affect outcome?
M. Lütolf, F.F. Immer, N.B. Aydin, M. Stalder, L. Englberger, F.S. Eckstein, J. Schmidli, T. Carrel (Bern)
Objective: Aortic cross clamping (ACC) has been shown to increase the incidence of cerebrovascular accidents (CVA) and is assumed to adversely affect neurocognitive outcome. Acute type A aortic dissection
(AADA) can be operated with or without clamping the dissected ascending aorta. Aim of the present was
to analyse the effect of ACC in AADA on outcome.
Methods: 275 consecutive patients who underwent surgery for AADA have been analyzed. All in-hospital
data have been assessed and a follow-up, focussing on Quality of life (assessed with the SF-36, was
performed. Data have been analyzed for patients with and without ACC.
Results: In 74 patients (26.9%) ACC during cooling was avoided. Patients characteristics were similar in
both groups. Average ACC-time was shorter in patients without primary ACC (71.0 vs. 87.0min; p<0.05),
similar modality of cerebral protection were applied in both groups. We found no significant differences
looking at reversible and persistent CVA (without ACC: 23.0% vs. with: 18.9%; p=ns) and in-hospital
mortality (without ACC: 14.9% vs with: 12.4%; p=ns). Follow-up 2.4 years after surgery showed a trend
towards an impaired SF-36 score in patients who underwent surgery with ACC (with ACC: 86.3 vs without
ACC: 91.3; p=0.08).
Conclusion: Early outcome, especially CVA, in surgery of AADA was not affected by aortic cross clamping
in our series. However, despite similar pre- and perioperative characteristics QoL tends to be lower in
patients with ACC, which may reflect a certain additional brain damage, which may be related to microembolisation (HITS) due to ACC.
58.4
Drug eluting degradable synthetic vascular prosthesis: A step towards shelf-ready coronary artery bypass grafts
F. Innocente, B. Nottelet, E. Pektok, J.C. Tille, D. Mandracchia, M. Moeller, R. Gurny, A. Kalangos, B.H. Walpoth (Genève)
Objective: Small calibre vascular prostheses (<6mm) for cardiovascular application are unsatisfactory.
The main reasons for failure are early thrombus formation and late intimal hyperplasia and infection. To
overcome these drawbacks we manufactured biodegradable small calibre vascular prosthesis using
electrospun polycaprolactone (PCL)-based nanofibres with slow releasing anti-inflammatory or anti-proliferative drugs.
Methods: Electrospun PCL solution containing Dexamethasone or Paclitaxel (0-10% w:w) was used to
prepare non-woven nanofibre-based 2mm ID prosthesis. Mechanical, morphological properties and drug
release were studied in vitro. Patency, degradation, tissue reaction and drug effect (morphology) were
studied in vivo. Infrarenal abdominal aortic replacement was carried out with non-drug loaded and with
drug loaded prostheses in 45 rats and followed up to 6 months.
Results: In vitro the prostheses showed a controlled morphology mimicking extra-cellular matrix (fibre
diameter 500-2000nm) with mechanical properties similar to those of native vessels (tensile stress >
1.4MPa, tensile strain > 100%). Drug loading had no negative impact on mechanical properties and
65
drugs were released in a controlled manner over 1 month. In vivo angiography showed no difference in
patency among the non-drug loaded and drug loaded prostheses (94%) and no aneurysmal dilatation
was found. Major morphologic differences were found between the non-drug loaded and drug loaded
prostheses, e.g. minimal inflammation in Dexamethasone-eluting grafts and minimal cell ingrowth in
Paclitaxel-eluting grafts. Confluent neoendothelialisation (CD31+) with minor intimal hyperplasia (morphometry) was found after 6 weeks in the non-drug loaded grafts.
Conclusion: Degradable, electro-spun, nanofibre, polycaprolactone prostheses are promising since, in
vitro they maintain their mechanical properties (regardless of drug loading), and in vivo show good patency, re-endothelialise and remodel with autologous cells. Drug loading induces less inflammation and
tissue reaction and thus is a promising alternative as shelf-ready coronary bypass grafts, but long-term
follow-up studies are needed to confirm the usefulness of drug-releasing, biodegradable scaffolds for
cardiovascular clinical applications.
58.5
Micro implantable pump to restore the atrial kick in chronic atrial fibrillation: Is this an alternative to lifelong anticoagulation?
P. Tozzi1, D. Hayoz2, F. Salchli3, E. Ferrari1, G. Siniscalchi1, L.K. von Segesser1 (1Lausanne, 2Fribourg, 3Yverdon-les-Bains)
Objective: Patients with chronic atrial fibrillation (AF) need lifelong anticoagulation to reduce the risk
of embolic stroke. However, the anticoagulation treatment causes itself hemorrhagic stroke in 1 to 3%
patients/year. Atripump is a motorless, volume displacement pump based on artificial muscle technology that could reproduce the pump function of normal atrium. If the pump is placed outside a chronic
fibrillating atrium it could help to prevent blood clots due to blood stagnation and eventually avoid anticoagulation therapy. An animal study has been designed to assess mechanical effects of this pump on
fibrillating atrium.
Methods: Atripump (Nanopowers, Switzerland) is a dome shape silicone coated nitinol actuator 5 x
45mm. The dome is sutured on the external surface of the right atrium (RA). A pacemaker like control
unit drives the dome and the dome provides the mechanical support to the blood circulation. In 5 adult
sheep, under general anaesthesia, the right atrium was surgically exposed and the dome sutured onto
the epicardium. AF was induced using rapid epicardial pacing (600 beats/min, Biotronik, Germany). Animals didn‘t received anticoagulant treatment. A Swan-Ganz catheter was inserted in the left jugular vein
to measure the central venous pressure and pulmonary pressure. Computation of the ejection fraction
(EF) of the right atrium was obtained with intracardiac ultrasound (ICUS) inserted in the right jugular vein.
Right atrium EF was calculated in baseline, AF and Atripump assisted AF conditions. Major hemodynamic parameters and dome temperature were acquired as well. Sheep were sacrificed at the end of the
experience.
Results: Sheep weight was 65±4 Kg. Dome’s contraction rate was 60/min with power supply of 12V,
400mA for 200ms and run for 2 consecutive hours. Mean temperature on the right atrium surface was
39±1.5 ºC. In 2 animals, after 20 min of AF, a small thrombus appeared in the right appendix (ICUS assessed) and was washed out once the pump was turned on. Detailed results are presented in table 1.
Mean Heart Rate Mean Arterial Pressure (mmHg) Mean Pulmonary Pressure (mmHg) Central Venous Pressure (cmH2O) RA Systolic Surface (cm2) RA Diastolic Surface (cm2) RA Ejection Fraction (%) Baseline 67±12 75±22 16±2 8±2 5.2±0.3 6.8±0.3 31% AF 89±24 70±13 15±2 15±6 6.2±0.1 6.5±0.1 5% Assisted AF
85±21
69±22
17±3
12±5
5.4±0.3
6.4±0.2
20%
Conclusion: The Atripump seems to restore the atrial kick in fibrillating atrium and washes blood out the
right atrium. This mechanical support provides also an anti coagulant effect. Possible clinical implications
in patients with chronic AF are prevention of embolism of cardiac origin and avoidance of hemorrhagic
complication due to chronic anticoagulation.
58.6
Reduced incidence of atrial fibrillation after cardiac surgery by continuous wireless monitoring of oxygen
saturation on the normal ward and resultant oxygen therapy for hypoxia
M. Wilhelm, D. Kisner, M. Lachat, G. Zünd, M. Genoni (Zürich)
Objective: Monitoring of cardiac surgical patients after transfer from the ICU to the normal ward is incomplete. Undetected hypoxia, however, is known to be a risk factor for occurrence of atrial fibrillation. We have
utilized Auricall® for continuous wireless monitoring of oxygen saturation and heart rate until discharge.
The object of the study was to analyze if oxygen therapy as a result of Auricall® alerts of hypoxia can
decrease the incidence of postoperative atrial fibrillation.
Methods: Auricall® is a wireless portable pulse oximeter. An alert is generated depending on preset
threshold values (heart-rate, oxygen saturation). Over a period of 6 months, 119 patients were monitored
with the Auricall® following CABG and/or valve surgery. Oxygen therapy was started subsequent to an
oxygen saturation below 90%. These patients were compared with a cohort of 238 patients of the time
period before availability of Auricall®. The patient characteristics were comparable in both groups. In a
retrospective study, the incidence of atrial fibrillation was measured in both groups.
Results: In the subgroup of patients with CABG with our without simultaneous valve surgery , Auricall®
monitoring resulted in a significantly reduced incidence of atrial fibrillation (14% vs 26%, p=0.016).
In the subgroup of patients with valve surgery only, no significant difference was noted (37% vs 47%,
p=0.519).
Conclusion: Continuous monitoring of oxygen saturation on the normal ward and subsequent oxygen
therapy for hypoxia can reduce the incidence of atrial fibrillation in a subgroup of patients after cardiac
surgery. Prospective randomized trials are warranted to confirm these data.
66
58.7
The Contegra Bovine Jugular Vein Graft versus the Shelhigh Pulmonic Porcine Xenograft for RVOT-reconstruction – a comparative study
O. Loup, A. Kadner, F. Schönhoff, M. Pavlovic, M. Schwerzmann, J. Pfammatter, T. Carrel (Bern)
Objective: The search for an alternative to homografts for RVOT reconstruction is still ongoing. As “offthe-shelf” available alternatives, the Contegra bovine jugular vein graft (CBG) and the Shelhigh pulmonic
porcine xenograft (SPG) are currently the most frequently implanted valve conduits. Concerns regarding
longevity of these grafts are mounting. Here, we report our results using CBG and SPG for RVOT-reconstruction.
Methods: The mid-term function of n=91 conduits, implanted (34 CBG, 57 SPG) in 80 patients (mean
age 12.9±15.8years) for RVOT-reconstruction (44 TOF, 3 PA, 1 PI, 4 PS, 3 DORV/PS, 3 DORV/TGA, 7
TGA/VSD/PS, 4 TAC, 11 Ross procedures) was analyzed. Primary endpoints were death, re-operation,
re-intervention or significant conduit stenosis (RV-PA-gradient>50 mmHg). Follow-up was performed by
echocardiography and MRI. Immunohistopathological and statistical methods were applied for analysis.
Results: During a mean follow-up of 34 ±25 months (CBG 55±30, SPG 23.3±12.5), 8 CBG patients
(24%) sized 12mm (n=2), 14mm (n=1), 16mm (n=2), 18mm (n=1), 22mm (n=2), and 9 SPG patients
(16%) sized 10mm (n=1), 12mm (n=1), 14mm (n=3), 23mm (n=1), and 25mm (n=3) required replacement of their stenosed conduit. Mean time to replacement for CBG was 27±21 and for SPG 13±7 months,
respectively. The predominant mode of failure was the formation of a stenotic membrane at the distal
anastomosis in CBG, while a generalized neointimal proliferation was observed in SPG. Immunohistopathology demonstrated a chronic inflammation process with lymphocytic infiltration in both grafts.
Conclusion: Both conduits mainly fail in the first 24 months without significant difference (p=0.06), and
are subject to a chronic inflammatory reaction following implantation. Small size appears not to present
an independent risk factor for early failure (p=0.53).
58.8
Mechanical circulatory support for terminal heart failure – the Zürich experience with LVAD and BVAD
since initiation of the assist device programm in 1999
M. Wilhelm, M. Lachat, R. Prêtre, S. Salzberg, V. Hinselmann, G. Noll, F. Ruschitzka, M. Hermann, M.I. Turina, M. Genoni (Zürich)
Objective: The increasing number of patients with terminal heart failure who deteriorate under medical
treatment makes a functioning mechanical circulatory support programm a requirement for each heart
failure center.
Methods: The programm started in October 1999 with the availability of the DeBakey LVAD. Since then,
43 assist devices (30 LVAD, 3 RVAD, 10 BVAD) were implanted in 42 patients (pts). In the early era, the
DeBakey LVAD was used in 17 pts (40±17 yrs, 9 DCM, 6 ICM, 2 congenital, 3 ECMO, 2 IABP). Since 2004,
the Berlin Heart INCOR was used as LVAD (13 pts, 54±6 yrs, 6 DCM, 7 ICM, 4 IABP, 1 ECMO) and the
EXCOR for BVAD or RVAD (13 pts, 43±15 yrs, 7 DCM, 1 myocarditis, 2 ICM, 2 congenital, 1 post-transplant
right heart failure, 5 ECMO).
Results: Cumulative support of LVAD pts was 3139 days (DeBakey 1181, INCOR 1958) with a mean support of 105±132 days (DeBakey 70±78, 150±168) and a maximum support of 355 (DeBakey) and 707
days (INCOR). In EXCOR pts, cumulative support was 2350 days (181±129 days, maximum: 380 days).
In the LVAD group, 16 pts (53%) were transplanted (DeBakey: 8/17 (47%), INCOR: 8/13 (62%)), 13 pts
died (DeBakey 9/17 (53%), INCOR: 4/13 (31%)), and one INCOR patient was switched to a BVAD. In the
BVAD group, 7 pts were transplanted (54%), one was weaned (8%), four are currently on support (30%),
and one died (8%). Fourteen pts were treated as outpatients (7 LVAD, 7 BVAD). While being on support,
four went back to work (3 LVAD, 1 BVAD), one BVAD patient back to school. In the LVAD group, adverse
events were pericardial bleeding in 2 pts (1 DeBakey, 1 INCOR), neurological events in 4 pts (2 DeBakey,
2 INCOR), device-related infection in 3 pts (1 DeBakey, 2 INCOR), hemolysis in 4 pts (all DeBakey). In
BVAD pts, pericardial bleeding occurred in two pts, neurological events in none, bacterial contamination
of the cannula site in 10 pts (sepsis in one patient). In 2 BVAD pts, the right ventricular pump chamber was
exchanged due to thrombus formation. In total, 28 of 42 pts (67%) could be transplanted (55%), weaned
(2%) or are currently on support (10%).
Conclusion: Mechanical circulatory support can be life-saving in a large number of pts with severely advanced heart failure who would otherwise not survive. The frequency of adverse events is low, and there is
a good chance to return to a nearly normal life. The experience of the interdisciplinary team is an important
factor which determines the quality of the programm.
58.9
Small incision big results – Percutaneously aided minimally invasive aortic valve replacement
L. Melly1, C. Huber2, D. Delay2, F. Stumpe2 (1Sierre, 2Lausanne)
Objective: Aim of the study was to introduce minimally invasive aortic valve surgery with minor risk to the
patients and to evaluate the results with regards to the technique it self.
Methods: Of 22pts. admitted from August to November 2007 to the Hospital of Sion, Valais for isolated aortic valve replacement ; 8pts (2f/6m 70.6±11.7y) underwent minimally invasive aortic valve replacement
technique (miniAVR) and 14pts (8f/6m 70.5±8.4y) got the standard full-sternotomy approach (AVR).
All miniAVR pts had a first time hemi-sternotomy (L-shaped from jugulum to the fourth right intercostal
space via an 8cm long skin incision. For aortic cannulation we used a 22F EOPA cannula (Medtronic) and
percutaneous venous vacuum assisted drainage was performed with a 21F Bio-Medicus multistage percutaneous cannula (Medtronic) in 6pt or with a 22F percutaneous fem-flex II cannula in 2pt (Edwards).
Vacuum assisted venous drainage and intrapericardial CO2 flooding was used in all mini-AVR pts. The
pts were included into the mini-AVR group after full consent and at the discretion of the surgeon in order
to minimize risk. Typical exclusion criteria included: Reopertion, aortic insufficiency>2, obesity, EF<40%,
severe calcification of the ascending aorta.
Results: Data is displayed as mini-AVR followed by AVR. All pts had significant aortic stenosis, preoperative
variables did not differ significantly in both groups. BSA 1.9±0.1/1.8±0.1m2, LVEF 56.8±5.9/55±8.7%,
Afib 0/3pts, sp MI 0/1pt. Operative times were longer in the mini-AVR groups: Overall operative time
181±19/145±28min, bypass time 71±13/56±11min, aortic cross clamp time 54±10/43±8min. All
three variables decreased over time due to the learning curve in the min-AVR group but remained stable
in the AVR group. No mini-AVR pt required conversion to full sternotomy. No pts underwent reoperations
for bleeding and no pts experienced MI, stroke or dialysis. One pt in the AVR group required temporary
IABP for weaning from the CPB. Length of stay in the ICU was 1.5±1.1d compared to 4.3±4.2d including
one pts with a 14d ICU stay in the AVR group due to pharmacologically induced agranulocytosis. Patients
remained intubated for 7.0±7.4/9±4.7h. Overall length of stay was 11.1±3.5/17±7.0d. Five (62.5%) of
the mini-AVR pts were discharged home compared to 5 (35%) pts of the AVR group. In both groups 1
pt was readmitted for a sternal wound infection. The mini-AVR pt got wire removal 14d after surgery and
was treated with vacuum assisted dressings. His sternum remained stable throughout no rewiring was
necessary. The second pt from the AVR group underwent sternal rewiring after wire removal despite of
identical wound dressings. Perioperative, inhospital and 30-day-mortality was 0 in either group.
Conclusion: Minimally invasive aortic valve surgery via the percutaneously aided upper hemi-sternotomy
approach can be performed without mortality and reasonable mobility in selected patients. Careful patient selection is essential for the successful introduction of new surgical technique. A randomized study is
mandatory in order to assess outcome differences of both techniques.
Posters (Fortsetzung)
P
P 19
Retrograde thrombectomy for acute superior mesenteric artery thrombosis as a life saving procedure
during laparotomy for complete small bowel ischemia
P. Bucher, J. Sierra, F. Pugin, S. Ostermann, F. Ris, Ph. Morel (Genève)
Objective: Acute thrombo-embolic occlusion of the superior mesenteric artery (SMA) is potentially fatal
vascular and visceral emergency that requires early diagnosis and rapid restoration of mesenteric blood
flow. Selective thrombolysis has been employed for this life-threatening event. Although failed thrombolysis is a well known phenomenon, which is directly connected with bowel necrosis, emergent laparotomy,
and eventually patient death, little progress has been made in its treatment strategy.
Methods: We report the case of a 42 years old HIV positive patient presenting with acute abdomen for
which a diagnosis of acute superior mesenteric artery thrombosis with diffuse small bowel ischemia was
made on computed tomography scanner.
Results: An emergency laparotomy was undertaken which confirmed complete small bowel ischemia
and during which revascularization of the superior mesenteric artery was attempted. Retrograde thrombectomy of the superior mesenteric artery was successfully performed using fogarty catheter through
a trans mesenteric approach of this artery. Therapeutic anticoagulation with heparin was started intraoperatively. A short segmental small bowel resection (20cm) was necessary at this time with temporary
jejunostomy. Planned relaparotomy at 48 hours revealed complete small bowel recovery and bowel continuity was restored. Post-relaparotomy recovery was uneventful and patient is well at 6 months postdischarge.
Conclusion: Retrograde surgical thrombectomy may be an effective approach in case of acute superior
mesenteric artery thrombosis when laparotomy is indicated due to severe small bowel ischemia. This approach may represent a life saving procedure in case of diffuse and complete acute superior mesenteric
artery bed ischemia.
P 20
Chronic abdominal pain caused by the pelvic congestion syndrome
T. Zingg, R. Inglin, H.M. Hoogewoud, J. Michel, B. Egger (Fribourg)
Objective: Chronic abdominal or pelvic pain is a common and often disabling complaint in women of
childbearing age with a substantial psychosocial and economic impact. Patients suffering from such
pain typically have undergone multiple non-invasive or invasive investigations, before diagnosis is achieved, if ever. In the US, 35% of all explorative laparoscopies are performed for unexplained chronic pelvic
pain and not less than 15% of all hysterectomies are reported to be processed for the same reason. One
well recognized but still underdiagnosed cause of chronic abdominal or pelvic pain is the pelvic congestion syndrome (PCS), an entity obviously still unknown to many clinicians.
Methods: We report the case of a 28 year old female who has been suffering from chronic pain in her left
lower abdomen for a year with several exacerbations. The pain usually irradiated to the back and was
always worse in erect position. The patient also reported of dyspareunia. Physical examination revealed
a soft abdomen tender to palpation with a maximum in the left lower quadrant. Laboratory results were
always normal. Endovaginal ultrasound showed cystic ovary disease and a hormonal treatment was
initiated. Following that the patient underwent multiple investigations including laparoscopy, without any
obvious pathological findings. However, an abdominal CT-scan demonstrated a dilated left-sided ovarian vein and the suspicion of pelvic congestion syndrome was raised. A subsequent venography indeed
showed a significant dilation of the left ovarian vein and the patient also suffered from her typical pain
pattern during injection of the contrast medium. Following that the sclerosing agent (Polidocanol 5%)
was injected selectively followed by coiling the vein. Shortly after this endovascular treatment, the patient
remained completely asymptomatic.
Results: The link between pelvic pain and ovarian vein insufficiency was first shown by Taylor et al (Am
J Obstet Gynecol 1949). Ovarian vein insufficiency, the counterpart to a varicocele in males, occurs in
about 10% of females and is much more frequent on the left than the right side due to the drainage into the
left renal vein. According to the literature about 60% of the patients with incompetent ovarian veins suffer
from PCS. A hormonal component to the aetiology is suspected because cystic ovary disease is present in
> 50% of patients and PCS is rarely seen in postmenopausal women. Other risk factors are family history
of varicosis and multiparity. Symptoms are typically uni- or bilateral, usually worse in erect position and relieved by lying down. Dyspareunia, found in 70% of the cases, together with ovarian point tenderness was
found to be 94% sensitive and 77% specific for PCS. Diagnosis is often difficult to achieve since the supine
position held during most imaging procedures (CT, MRI, US) makes the venous congestion less obvious.
The gold standard for diagnosis remains the direct visualization of reflux into and dilation of the left ovarian vein by venography. Technical success rates of endovascular treatment by embolization and coiling is
as high as 98% and complete symptomatic relief can be obtained in more than 75% of patients.
Conclusion: PCS should be considered in female patients with longstanding pelvic or abdominal pain for
which no alternative diagnosis can be established. Endovascular treatment is simple, minimally invasive
and has a very high rate of success.
P 21
Inferior epigastric artery for revascularisation of a small accessory renal artery in kidney transplantation
U. Herden, S.W. Schmid, D. Inderbitzin, C.A. Seiler, D. Candinas (Bern)
Objective: Revascularisation of accessory graft arteries to the recipient`s inferior epigastric artery is a
rare technique in kidney transplantation. This study analyses the outcome of patients undergoing kidney
transplantation using this technique at our institution.
Methods: All patients with a kidney transplantation between 2004 and 2007 were prospectively analysed with special attention to cases with graft anastomosis to the recipient`s epigastric artery. Graft
and patient’s survival, incidence of postoperative vascular and urological complications, acute tubular
necrosis or acute rejection were evaluated over time.
Results: In 3 out of 158 patients an anastomosis to the recipient`s inferior epigastric artery was performed (in 2 patients an anastomosis to an accessory upper pole graft artery and in 1 patient an anastomosis to an accessory lower pole graft artery). All 3 patients are actually alive with well functioning renal
grafts (9, 39, 40 months after kidney transplantation). No patient suffered from vascular or urological
complications, acute tubular necrosis or acute rejection.
Conclusion: Our data suggest that anastomosis of small accessory graft arteries to the recipient`s inferior epigastric artery is a feasible and safe technique in kidney transplantation.
P 22
Tissue expander for bowel protection in adjuvant radiotherapy to a retroperitoneal sarcoma
H. Gelpke, F. Grieder, A. Stolz, U. Meier, M. Decurtins (Winterthur)
Objective: The most powerful therapeutic modality in retroperitoneal sarcomas seems to be a combination of surgery and radiotherapy. Radiotherapy can be limited by the dose administered to the small
bowel. To displace the small bowel it is reported to insert tissue expanders before radiotherapy. All reports
using tissue expanders in the treatment of retroperitoneal sarcoma are for neoadjuvant external beam
radiotherapy. We report a case in the setting of adjuvant radiotherapy.
Methods: Case report.
Results: A 60 years old female had a history of back pain for some month followed by a resistance in the
left upper abdominal quadrant, nausea and deterioration in general condition. CT scan and a core needle
biopsy demonstrated a liposarcoma of 26 to 17 to 17 centimetres. Interdisciplinary board discussion
decided for a neoadjuvant radiotherapy followed by resection. The consulted specialised oncologist considered immediate resection because of the rapid growth of the tumour. The tumour was removed en bloc
with the left colon, the left kidney and adrenal. A thin capsule was found to border the tumour. Towards
the retroperitoneal tissue it was possible to cover the tumour by a layer of the psoas muscle. The weight of
the tumour was 6.2 kilograms. Colonic anastomosis was done by a running suture. To enable adequate
dose for adjuvant radiotherapy it was necessary to displace the small bowel from the left retroperitoneal
cavity. This was realised by placing a tissue expander filled with 1000ml of saline fluid. The expander
was fixed by a absorbable mesh and covered by the greater omentum. In the postoperative course a left
sided chyleous pleural effusion had to be drained but was otherwise uneventful. Histology of the tumour
showed a dedifferentiated liposarcoma without infiltration of the removed organs and the muscle. The
minimal margin was 1 to 2 millimetres. The resection was estimated to be R0. Seven weeks after the
operation external beam radiation could be started and over 6 weeks be completed to 54Gy (30 fractions
of 1.8 Gy with 18MV photons). No diarrhoea and no other adverse events than nausea were detected. The
pleural effusion disappeared completely.
Conclusion: In retroperitoneal sarcoma tissue expanders may be helpful to protect the small bowel while
external beam radiation and allow adequate dosage of the radiotherapy.
P 23
Gallbladder volvulus: an unusual presentation of an acute cholecystitis
T. Zingg, S. Sugasi, M. Menth, J. Michel, B. Egger (Fribourg)
Objective: Gallbladder volvulus is a rare entity which is described in the literature with about 400 reported
cases since 1898, when Wendel (Ann Surg 1898) first published about it. Anatomic variations of the
peritoneal attachments between the gallbladder and the liver are present in all cases. This leads to a so
called “floating gallbladder” prone to twisting around its narrow pedicle. Direction of the torsion can be
clock- or counterclockwise, both found with equal frequency. The clinical presentation and imaging findings of gallbladder volvulus are hard to distinguish from the much more frequent simple acute cholecystitis without torsion. For gallbladder volvulus however, conservative treatment with antibiotics is not an
option. We would like to report a case of gallbladder volvulus, briefly review the literature and emphasize
on the importance of early recognition and treatment of this rare disease.
Methods: We report the case of a 91 year old female patient presenting at our emergency department with
acute onset of abdominal right upper quadrant pain. Physical examination showed tenderness on palpa-
67
tion with signs of peritoneal irritation. Laboratory tests showed an inflammatory syndrome and findings of
an ultrasound examination indicated acute cholecystitis in the presence of a large gallstone. Subsequently the patient underwent emergency laparoscopy for suspected acute cholecystitis. On exploration, an
enlarged, tense and profoundly livid gallbladder was found (Im 1). The organ was twisted 180° clockwise
around its pedicle with only a small area being extraperitoneal on the liver surface, allowing a high degree
of mobility. After detorsion (Im 2 and 3), a clear-cut livid demarcation indicating ischemic necrosis of the
gallbladder could be identified beginning at the base of the twist. Laparoscopic cholecystectomy was
successfully performed. Pathology confirmed complete hemorrhagic necrosis of the gallbladder.
Results: A review of the literature shows that in more than 80% of cases, the diagnosis of gallbladder volvulus was established only at the time of surgical exploration, often for clinical deterioration while treating
with antibiotics. Gallbladder volvulus typically occurs in thin, elderly female patients. Lau (Aust N Z J Surg
1982) has proposed 3 triads of clinical signs suggestive for gallbladder torsion. These include symptoms
(abdominal pain, short duration, early vomiting), physical signs (abdominal mass, absence of toxemia,
pulse-temperature discrepancy) and physical characteristics (thin, elderly, kyphosis) and may be helpful
to distinguish it from simple acute cholecystitis. Interestingly, gallstones are not a consistent risk factor,
present in only about 25% of patients with a volvulus. Specific signs in US- or CT examinations are a markedly enlarged „floating“ gallbladder with a continuous hypoechoic line indicating edematous changes
in the wall. Early laparoscopic cholecystectomy is the treatment of choice with a reported mortality rate
below 5%.
Conclusion: Gallbladder volvulus is a rare but potentially life threatening condition requiring emergency
surgery. Conservative antibiotic treatment would invariably lead to treatment failure, gallbladder necrosis
and perforation. Clinical suspicion should arise in elderly and kyphotic female patients with suspected
simple cholecystitis, especially in case of non-response to antibiotics. In such cases, early laparoscopy
should be considered.
P 24
Von der Arthroskopie zur Sigmaresektion – Streptokokkus bovis Arthritis als stiller Indikator für ein Karzinom des Dickdarms, eine Fallpräsentation
M.L. Zürcher, T. Beck, D. Oertli (Basel)
Objective: Einleitung. Wir präsentieren eine Fallvorstellung, bei welcher eine septische Arthritis mittels
Streptococcus bovis eine Abklärung und letztendlich Diagnose eines gastrointestinalen Malinoms einleitete.
Methods: Fallbeispiel. Eine 89-jährige Patientin stellte sich auf der Notfallstation vor mit seit vier Tagen bestehenden Ellbogenschmerzen rechts und einer deutlichen Bewegungseinschränkung. Im Gelenkpunktat sowie in den Blutkulturen liessen sich Streptrococcus bovis nachweisen. Das Gelenk wurde deswegen
arthroskopisch gespült und resistenzgerecht wurde eine Antibiotikatherapie mit Rocephin und Amikin initiiert. In Anbetracht der bekannten Assoziation von S. bovis mit einem Malignom des Colons wurde in der
folge eine Coloskopie durchgeführt, welche einen bisher asymptomatischen exophytisch wachsenden
exulzerierten Sigmatumor im Bereich des Sigmas zeigte. Bioptisch ergab sich ein mässig differenziertes Adenokarzinom. Ein Staging-CT Abdomen zeigte bis auf eine zystische Struktur im linken Ovar keine
weitere Pathlogie. In kurativer Absicht wurde eine Sigmaresektion mit Adnexektomie links durchgeführt.
Histologisch zeigt sich ein Adenokarzinom Stadium pT3, pN0 (0/9), M0; G2, R0. Der postoperative Verlauf gestaltete sich komplikationslos.
Results: Diskussion. S. bovis gehört in 2.5-14% der menschlichen Individuen zur normalen Dickdarmflora.
Er ist als Verursacher von Bakteriämie und Endokarditis, sowie von Harnwegsinfekten gut dokumentiert.
Es wurden zahlreiche septische Arthritiden und Infekte von Gelenksimplantaten beschrieben. Ein Bezug
zwischen septischen Endokarditiden und Neoplasien des Dickdarmes wurde bereits 1951 vermutet, der
Zusammenhang zwischen S. bovis und kolorektaler Neoplasie wurde 1974 erstmals beschrieben und
seither wiederholt dokumentiert. Es wird vermutet, dass das Vorhandensein von Mukosa-Läsionen den
Keim-Eintritt in die Blutbahn ermöglicht und dass somit die Entstehung einer septischen Besiedelung von
Herzklappen oder Gelenken ermöglicht wird. Es wurde im Zusammenhang mit S.bovis-Endokarditis auch
ein gehäuftes Vorkommen von Leberdysfunktionen beobachtet, möglicherweise bedingt durch eine Besiedelung des Leberparenchyms via Pfortader.
Conclusion: Schlussfolgerungen. In Anbetracht der Tatsache, dass sich bei 60-75% der Patienten mit
einer S. bovis-bedingten Endokarditis ein bisher nicht diagnostiziertes Malignom des Gastrointestinaltrakts nachweisen lässt vermuten, dass das Vorhandensein einer durch S. bovis verursachten Bakteriämie als Tumor-Indikator benutzt werden kann. Die eingehende Beurteilung des gesamten Dickdarmes
mittels Coloskopie ist daher in einem solchen Falle dringend zu empfehlen. Es wurden auch Fälle einer
verzögerten Karzionmentwicklung bis mehrere Jahre nach dem Erregernachweis beobachtet, weshalb
auch Patienten mit einer initial unauffälligen Coloskopie als künftige Risikopatienten betrachtet und daher
engmaschig kontrolliert werden sollten.
P 25
Verschluss einer postoperativen perinealen Hernie mittels laparoskopischer Netzeinlage
C. Steinmann, G. Teufelberger, Th. Kocher (Baden)
Objective: Die perineale Hernie (PH) ist eine seltene Komplikation nach abdominoperinealer Rektumexstirpation. Der Verschluss einer solchen Hernie ist eine chirurgische Herausforderung. Zur Reparation stehen verschiedene Methoden zur Verfügung. Wir berichten über eine Versorgung mittels laparoskopischer
Netzeinlage.
Methods: Falldarstellung
Results: Bei einem 60-jährigen Mann wurde nach neoadjuvanter Vorbehandlung wegen tief-sitzendem
Rektumkarzinom eine laparoskopische abdominoperineale Rektumexstirpation (APR) mit total mesorektaler Exzision durchgeführt. Im postoperativen Verlauf kam es zu einer perinealen Wundheilungsstörung,
welche unter konservativer Therapie abheilte. Knapp 4 Monate postoperativ berichtete der Patient über
ein Reissen in der Abdominalgegend und pelvin nach einem Niessanfall. In der Folge manifestierte sich
eine PH, welche den Patienten zunehmend störte. Mittels MR-Tomografie konnte die Beckebodeninsuffi-
68
zienz mit peritonealer Ausstülpung dokumentiert werden. Die operative Versorgung erfolgte laparoskopisch. Nach Adhäsiolyse und Reposition der Dünndarmschlingen zeigte sich die perineale Hernienlücke.
Zur Defektdeckung wurde ein 10x10cm grosses Composite-Netz pelvin platziert und mit mehreren nicht
resorbierbaren Nähten fixiert.
Conclusion: Bei PH unterscheidet man kongenitale, primäre und sekundäre Formen. Bei der am häufigsten sekundären Form handelt es sich um eine postoperative Komplikation nach pelvinen Eingriffen (APR,
Proktektomie, Coccygektomie, Sakrektomie, Hysterektomie oder pelviner Exenteratio). Nach APR tritt in
0.2 - 3.5% der Fälle eine PH auf. Verschiedene Faktoren sollen deren Auftreten begünstigen. Dazu gehören
das weibliche Geschlecht, die Bestrahlung der Beckenregion, ausserordentliche Länge des Dünndarms,
fehlender Verschluss des Beckenperitoneums sowie postoperative Wundinfekte. In vielen Fällen bleiben
die PH asymptomatisch und unentdeckt. Mögliche Beschwerden sind: Schmerzen, Probleme beim Sitzen, Ileus, Miktionsprobleme und/oder perineale Hautirritationen. Symptomatische sekundäre PH können
über einen perinealen, transabdominalen, kombiniert abdominoperineal oder über einen laparoskopisch
abdominalen Zugang behandelt werden. Neben einfacher Naht hat sich die Verwendung einer Netzverstärkung bewährt. In seltenen Fällen muss der Defekt mittels Verschiebeplastiken verschlossen werden.
P 26
Frantz tumor – a rare pancreatic neoplasm
R. Inglin1, T. Zingg1, R. Weimann2, J. Michel1, B. Egger1 (1Fribourg, 2Marly)
Objective: Introduction: Solid pseudopapillary neoplasm (SPN) of the pancreas, also known as Frantz
tumor, is an uncommon but distinct pancreatic neoplasm with low metastatic potential. It accounts for
1-3% of all pancreatic malignancies, while the overall mortality rate of the tumor has been estimated
to be around 2%. SPN belongs to the group of pancreatic neoplasms of uncertain origin and in fact, its
pathogenesis and clinical behavior are still unclear. Usually, 90% of patients are females and 85% of them
are less than 30 years old.
Methods: This is the report of a case of a 35-year old caucasian male patient, who presented with intermittent epigastric pain, nausea and vomiting. CT scan showed a 4-cm cystic mass involving the tail of the
pancreas which also displaced the adjacent splenic vessels without obvious infiltration. He underwent
distal pancreatectomy with en bloc splenectomy as well as cholecystectomy. Specimens were assessed
by a staff pathologist. He then recovered fast and well from the intervention and showed an uneventful
postoperative course with no signs of recurrence up to date.
Results: Discussion: SPN is a rare tumor of the pancreas that is diagnosed primarly in young women. In
discordance, the case we present here demonstrates a Frantz tumor in a young man. Age at diagnosis in
our patient confirms the experience of Goh et al. (J Surg Oncol 2007) who found the median age of the
patients with tumors in distal pancreas to be 10 years higher than with tumors in the head (26 years).
Because of the strong female predilection, sex-homone dependency of this tumor is controversially discussed. However, progesterone receptors (immunohistochemistry) are one of the typical findings in this
rare tumor. According to the literature, abdominal discomfort is the prevailing symptom associated in
some cases with a palpable mass, anorexia, and weight loss. Localisation of the neoplasm in the body or
tail of the pancreas has been described to be predominant in two series of 34 and 31 patients (Machado,
Surgery 2008), respecitvely. Lymph node involvement is very rare but distant metastases (most frequently
in the liver) have been described. Aggressive and complete surgical resection of these tumors is the treatment of choice even in the presence of metastases, since it may provide more than 95% cure rate and an
estimated 5-year survival of 95%.
Conclusion: Even though SPN is a rare entity it should be considered as differential diagnosis of cystic
pancreatic tumor, especially in young women. Treatment of choice consists of surgical resection with
synchronous resection of metastases, if present. Cure rate and prognosis are particularly good.
P 27
Pyoderma gangrenosum after totally implanted central venous access device insertion
I. Inan, P.O. Myers, S. De Sousa, R. Braun, K. Djebaili, Ph. Morel (Genève)
Objective: Pyoderma gangrenosum is an aseptic skin disease. Misdiagnosis or delayed treatment may
have disastrous consequences for patients.
Methods: A 90 years old patient with myelodysplastic syndrome, seeking regular transfusions required
totally implanted central venous access device (Port-a-Cath®) insertion. Fever and inflammatory skin
reaction at the site of insertion developed on the seventh post-operative day, requiring the device’ s explantation. A rapid progression of the skin lesions evolved into a circular skin necrosis. Intravenous steroid
treatment stopped the necrosis’ progression.
Results: The ulcerative form of pyoderma gangrenosum is characterized by a rapidly progressing painful
irregular and undermined bordered necrolytic ulcer. The aetiology of pyoderma gangrenosum remains
unclear. In about 70% of cases, it is associated with a systemic disorder, most often inflammatory bowel
disease, haematological disease or arthritis. In 25-50% of cases, a triggering factor such as recent surgery or trauma is identified. Treatment consists of local and systemic approaches. Systemic steroids are generally used first. If the lesions are refractory, steroids are combined to other immunosuppressive therapy
or to antimicrobial agents. Debridement or necrosectomy in postoperative PG is contraindicated . Elective
surgery for other indications should be deferred, and if unavoidable, it should be performed in conjunction
with systemic PG therapy.
Conclusion: PG represents a diagnostic challenge. In the presence of a patient with cutaneous inflammatory and necrotizing lesions one must consider PG as a differential diagnosis. Early diagnosis remains the
most important step to the successful treatment of pyoderma gangrenosum.
P 28
Enterobius vermicularis associated acute appendicitis
N. Zeh, V. B. Tahami, J. Michel, E.J. Stauffer, B. Egger (Fribourg)
Objective: Acute appendicitis is one of the most common inflammatory diseases of the gastrointestinal
tract. In the literature oxyuriasis (Enterobius vermicularis) has been shown to play a causal role in appendicular pain and chronic inflammation but relationships between the incidence of Enterobius vermicularis
(EV) and the origin of acute inflammation in the appendix are discussed controversially.
Methods: We report the case of a nine-year old boy who presented at our emergency department with
a 2-day history of abdominal pain. On clinical examination he presented a tenderness of the right lower
quadrant without signs of a peritonitis. Laboratory results revealed a normal white cell count and a normal
CRP. A sonographic examination was performed which was suspicious for an acute appendicitis.
Results: The patient underwent emergent laparoscopic appendectomy. Intraoperative findings showed
the typical signs of acute appendicitis with a thickened and very well vascularised appendix. After dissection of the mesentery by a bipolar cautery device the appendix was resected using a endoscopic
Hem-o-lok clip device (Fumedica, 5630 Muri, Switzerland). Somewhat shockingly we then observed at
the resection-line several moving pinworms protruding out. A careful cleaning and disinfection with Betadine solution was performed before over-sewing the resection-line with some PDS-5-0-sutures. Finally,
the abdominal cavity was rinsed with 10 litres of warm Ringer-solution. Histopathological examination
revealed numerous EV-species and they were also identified to be the cause of the acute inflammation
of the appendix. After initiating an antiparasitic therapy the patient recovered well and there was also a
complete uneventful follow-up.
Conclusion: The significance of EV-associated appendicitis is controversially discussed in the literature.
In a large study of a group in Wisconsin, USA, a retrospective review of 1549 appendectomies performed
at a major children‘s hospital during a 5-year period was reviewed (Arca, Pediatr Surg Int 2004). Of these
appendectomies, 21 specimens (1.4%) were found to contain EV. Fifteen of the appendectomies (0.96%)
were performed for symptoms of acute appendicitis; the remaining six were incidental appendectomies
in conjunction with other operations. Pathologic evaluation showed neutrophil or eosinophil infiltration in
all 15 of the specimens with acute appendicitis most probably caused by the pinworms. EV-associated
acute appendicitis is a rare disease (less than 1% of all acute appendicitis). Conclusion: EV infestation into
the appendix may be associated with acute appendicitis, „chronic appendicitis,“ perforated appendicitis,
but most often with no significant clinical symptoms. Treatment of EV-associated acute appendicitis consists of appendectomy and an antiparasitic therapy.
P 29
Peritoneal tuberculosis: think of it, confirm and treat it
S. Romy, R. Rosenthal, M.J.C. Matter, N. Demartines (Lausanne)
Objective: The incidence of Tuberculosis in developed countries decreased during the last century belongs currently increasingly to the differential diagnosis. Not only the increase of HIV or immunodefficient
patients but large population migration as well contribute to the appearance of new tuberculosis cases
in our country.
Methods: We report the cases of two patients. 1. A 41-year-old congolese man in good health living in Switzerland since 10 years, was investigated for diffuse abdominal pain with some abdominal distension.
Fifteen days before hospitalisation, an ombilical hernia had been operated extraperitoneally. Clinical examination showed abdominal sensitivity and ascites. White blood cell account was normal, CRP 300mg/l
and the HIV test negative. An abdominal CT scan showed ascites without other pathologies. 2. A 27-yearold somalian patient living in Switzerland since 2 years was investigated for abdominal pain, weight loss
and fever. Clinical examination revealed abdominal sensitivity without peritonism. White blood cell count
was normal, CRP 178mg/l and the HIV test negative. A thoraco-abdominal CT scan showed ascites and
intra-and retroperitoneal lymphadenopathies.
Results: In both cases, ascites was confirmed during laparoscopy. Furthermore, multiple miliary nodules
on the visceral and parietal peritoneum were found. Histopathologically, a granulomateous partially
necrotising inflammation with multinucleate giant cells was documented. Ziehl-Neelson staining and PCR
of mycobacterium tuberculosis complex were negative but after 20 and 17 days, respectively, culture
for mycobacterium tuberculosis was positive. A quadritherapy with isoniazide, rifampicine, pyrazinamide
and ethambutol was started and patients’ recovery was uneventful.
Conclusion: Tuberculosis is still present and has to be included in the differential diagnosis in many syndromes including abdominal pain even in Switzerland. The peritoneum is one of the most common extrapulmonary sites of tuberculosis. Laparoscopy is the diagnostic tool of choice.
P 30
Goblet cell carcinoid: a case report and recommended surgical treatment in literature
R.S. Jost, G. Wille, H. Gelpke, M. Decurtins (Winterthur)
Objective: The Goblet cell carcinoid is a rare tumor with histologic features of both adenocarcinoma and
carcinoid tumor. It is more aggressive than conventional carcinoid and arises mostly from the appendix
but can also occur in other parts of the small bowel. To our knowledge there are only 600 diagnosed
patients worldwide, mean age 59 years. We describe a case of a goblet cell carcinoid in a young patient
and give a review of commended surgical treatment in literature.
Methods: A 30 year old patient presented with clinical and radiological findings of intestinal obstruction
of the terminal ileum. He was diagnosed for Crohn‘s disease 3 years ago, based on endoscopic and
clinical aspects and compatible histology, suffering from segmental colitis and perianal abcess. Laparatomy showed a stricutring lesion in the terminal ileum and an infiltrating tumor mass with peritoneal
spreading, ileocoecalresection was performed. Only histology of the resected surgical specimen proved
the presence of a disseminated goblet cell carcinoid. From the resected specimen it remained histopathologically uncertain if adenocarcinoid coexisted with Crohn‘s disease and if origin of development was the
appendix or the terminal ileum. Postoperative chromogranin A blood levels were slightly elevated, octreo-
tid scintigraphy and thoracoabdominal tomography showed no evidence of extraabdominal metastases.
The patient was referred to a palliative chemotherapy with combined capecitabine(xeloda®), oxaliplatin
and bevazizumab (avastin®) without further surgical treatment due to intra-abdominal dissemination.
Results: –
Conclusion: Goblet cell carcinoid is a rare neoplasm. Due to its wide range of presentation (acute appendicitis, abdominal pain, abdominal mass/stricture, asymptomatic), this tumor should be considered
as a possible diagnosis in varied situation leading to abdominal surgery, also in young patients. Recommended surgical treatment for non-disseminated appendicular goblet cell carcinoid in literature is simple
appendectomy alone, except: a) histological high-grade tumors, b) cecal involvement or c) lymph node
metastasis. In these cases completion right hemicolectomy should be performed, but showed no significant 5-year-survival in a high-numbered retrospective study. In female patients some authors advocate
bilateral oophorectomy because of the high possibility of ovarian metastasis. Aggressive surgical cytoreduction to manage peritoneal seeding, as has been done with other neoplasms (ovarian and mucinous
cystadenocarcionma), remain controversial. In cases with obvious spread of the disease chemotherapy,
mostly with 5-FU/oxaliplatin and leucovorin is advised. According to the adenocarcinoma fraction of
goblet cell carcinoid in this case an additional therapy with bevazizumab (avastin®) was started.
P 31
Laparoscopic appendectomy can be performed safely during the third trimester of pregnancy
M. Giuliani, V. Schreiber, R. Schlumpf (Aarau)
Objective: Laparoscopic management of acute appendicits during the third trimester of pregnancy remains controversial and underreported (31 cases). A gestational age of 26-28 weeks has been considered as the upper limit for laparascopy by some authors. Acute appendicitis is the most common cause
of acute abdomen during pregnancy leading to appendectomy in 1/1500 pregnancies. Delay in diagnosis and therapy with appendiceal rupture and peritonitis increases the risk of preterm labor. Fetal losses
are up to 20% in cases of perforated appendicitis and up to 36% in generalized peritonitis compared
to < 5% in cases of uncomplicated appendicitis. The second trimester is considered the safest period
to perform surgery because of the small size of the uterus. Recently, some studies have demonstrated
that laparoscopic surgery can be performed safely during pregnancy regardless of gestational age. Presenting a case report we discuss this topic.
Methods: Case report. A 34 year old patient in the 29th gestational week presented with signs of peritonism
in the lower right abdomen, subfebrile temperature (37.8°C), nausea and elevated infection parameters
(Leukocytosis 11.8G/l, CRP 28.5mg/dl). Gynecological examinations and transvaginal ultrasound were
normal. Abdominal ultrasound showed no peritoneal fluid in the abdominal cavity, the appendix couldn’t
be detected. Diagnostic laparascopy was performed. Open trocar technique was used to insert a 10mm
trocar for the 30° optic 3cm above the umbilicus and a gangrenous appendicitis with purulent peritoneal
fluid into the abdomen was diagnosed. After insertion of a 5mm trocar in the midline infraumbilical and
a 10mm trocar in the right upper quadrant, laparoscopic appendectomy was performed. Microbiological
study of peritoneal fluid showed positive culture for E. coli and Cl. innocuum and antibiotic therapy with
Tazobac was prescribed for 5 days. Hospitalisation time was 7 days. During the 39th gestational week
the patient gived birth spontaneously to a term healthy newborn.
Results: Discussion. Impact of CO2 pneumoperitoneum on the fetus has been shown to be minimal keeping pneumoperitoneum pressure <15mmHg. Pneumoamnion and fetal loss from Veress needle injury
of the gravid uterus is rare but can occur. Therefore Hasson open trocar technique is recommended for
laparoscopy during late pregnancy. Port site locations have to be adapted to the size of the uterus. Left
lateral decubitus is recommended to prevent inferior vena cava syndrome. Obstetrical consultation for
perioperative monitoring of the fetus, tocolysis and Betamethason-induced lung maturation should be
obtained preoperatively.
Conclusion: Using appropriate techniques laparoscopic appendectomy is a safe and effective method to
treat acute appendicitis in pregnant women in all trimesters.
P 32
Appendiceal diverticulitis: what else? – Report of 3 cases and a review.
E. Pezzetta, M. Maternini, O. Martinet (Montreux)
Objective: Infectious disease of the appendix is a common clinical problem, in this setting acute appendicitis is encountered in the overhelming majority of patients. Nevertheless appendiceal diverticular disease
does exist as a well distinct entity, with a wide spectrum of presentation, which may give diagnostic or
therapeutic difficulties.
Methods: Three patients with different manifestations of appendiceal diverticulitis are presented with
particular emphasis on the clinical course, on surgical management and on the anatomopathological
picture of the disease.
Results: One patient presented with classic appendiceal right lower quadrant pain. Transumbilical videoassisted appendectomy was performed, the anatomopathological analysis confirmed an acute appendicitis, however an accompanying appendiceal diverticular involvement was observed. The second patient
was also admitted for acute right lower quadrant pain. During laparoscopic exploration an heavily inflamed appendix was noticed. Conversion to open surgery was necessary in order to perform the appendectomy. The histopatological analysis revealed a perforated appendiceal diverticulitis with an abscess
of the mesoappendix and periappendicitis. The postoperative course was uneventful but longer than for
standard acute appendicitis. The third case presented with long standing abdominal right lower quadrant
pain. CT scan showed thickening of the caecum and partial thrombosis of the superior mesenteric vein.
Despite prolonged antibiotherapy the patient condition did not improve with persisting fever and abdominal pain. Surgical exploration was then decided with a laparoscopy followed by an open ileo-caecal
resesection. Pathology showed a complicated appendiceal diverticulitis.
Conclusion: Appendiceal diverticulosis with diverticulitis is a known clinico-pathological condition. Surgeons need to be aware of this particular form of appendiceal inflammation because the clinical presentation and sometimes the appropriate diagnostic workup and treatment may be different from the more
classical and common picture of acute appendicitis.
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P 33
Radiofrequenz – Wundermittel bei Problemfällen?
T. Thenisch, M. Lüdin, J. Lange (St. Gallen)
Objective: Die Radiofrequenzablation von primären Lebertumoren und Lebermetastasen insbesondere
bei kolorektalen Tumoren ist mittlerweile gut etabliert. Auch an unserer Klinik wird sie zur Ergänzung der
klassischen Leberchirurgie erfolgreich und mit wenig Lokalrezidiven (6,5%) seit 1997 eingesetzt. Neben
diesen klassischen Indikationen kann die Radiofrequenzablation von parasitären und infektiösen Herden
in der Leber in schwierigen Fällen eine zusätzliche Therapieoption darstellen. In den vergangenen zwei
Jahren haben wir bei einer Patientin mit mehreren Echinokokkusherden sowie bei einem Patienten mit
multiplen Pilzabszessen die RFA angewandt.
Methods: Eine 48-jährige Patientin mit einer ausgedehnten Echinokokkose des linken Leberlappens und
der Milz wurde operiert. In der intraoperativen Sonographie fanden sich fünf zusätzliche Echinokkokusherde im rechten Leberlappen. Neben einer Splenektomie und einer Hemihepatektomie links wurden die
fünf zusätzlichen Herde mittels Radiofrequenz abladiert. Ein 22-jähriger Patient mit neudiagnostizierter
ALL und konsekutiver Chemotherapie wurde in der Aplasie wegen ausgedehntem Mucorbefall der Leber,
der Milz, des Magens und der Lunge operiert. Neben einer Splenektomie, einer Magenwedge- und einer
Unterlappenresektion wurden die Leberherde mittels RFA therapiert.
Results: Die Patientin mit den Echinokkokusherden zeigt in der Computertomographie 10 Monate nach
dem Eingriff keine Hinweise auf aktive Herde in der Leber. Bei dem Patient mit dem Mucorbefall verbessert
sich der Allgemeinzustand während den 15 Monaten nach dem Eingriff unter antimykotischer Therapie
laufend bei stabilen Restherden in der Bildgebung.
Conclusion: Die Radiofrequenzablation kann bei ausgedehntem parasitärem und infektiösem Befall der
Leber in schwierigen Fällen die etablierten Therapien durch Reduktion der infektiösen Herde unterstützen
oder einen kurativen Therapieansatz ermöglichen.
P 34
Abdominal sarcoidosis – differential diagnosis of an intraabdominal mass or lymphadenopathy
D. Perruchoud1, R. Inglin1, R. Weimann2, J. Michel1, B. Egger1 (1Fribourg, 2Marly)
Objective: Sarcoidosis, a systemic disorder of unknown origin, is characterized histopathologically by
noncaseating epithelioid-cell granuloma in the absence of organisms or particles. It can involve virtually
any organ, but most commonly the lungs, lymph nodes, eyes or the skin are affected. While the prevalence of sarcoidosis is 1-40/100’000, only 0.1 to 0.9% of the patients are symptomatic for involvement
of the gastrointestinal tract. However, the incidence of clinically silent intraabdominal organ involvement
may be much higher.
Methods: We present here two cases of abdominal sarcoidosis. The first case demonstrates a 40 year-old
male presenting with epigastric pain. CT-scan revealed multiple enlarged lymph nodes suspicious for lymphoma. Studies for infectious agents were negative. Diagnostic laparoscopy showed a typical macroscopic appearance of an abdominal carcinomatosis. Pathologic assessment of biopsies of the liver, lymph
nodes and peritoneal deposits concluded for a diagnosis of sarcoidosis. The second case describes a 39
year-old woman presenting with occasional abdominal discomfort. In the clinical examination a voluminous abdominal mass could be palpated. CT-scan further showed a tumor mass growing from the right
ovary and multiple intraparenchymatous nodules of spleen, liver and lungs. Histopathologic results after
right oophorectomy demonstrated a mature cystic teratoma (dermoid cyst) of the ovary, while liver and
myocardic biopsies were conclusive for sarcoidosis.
Results: Discussion: In systemic sarcoidosis intraabdominal lymph node and organ involvement is infrequent; in 60%-90% of these cases the liver is affected. Similarly, abdominal lymphadenopathy and
peritoneal nodules are extremely rare in sarcoidosis. In a review of 2100 abdominal CT scans showing
evidence of abdominal lymphadenopathy, only one was due to sarcoidosis (Deutch, Radiology 1987).
Peritoneal affection of systemic sarcoidosis may mimic carcinomatosis. Splenic, pancreatic and intestinal involvement have also been reported. Abdominal sarcoidosis may be underreported and bowel involvement should be considered in patients with biopsy-proven sarcoidosis and diarrhea.The occurrence
of neoplasia may precede, follow or occur concurrently with the diagnosis of sarcoidosis. A causal relationship between sarcoidosis and the occurrence of different neoplasms appears to exist. These include
tumors that affect the cervix, liver, lung, skin (melanoma and nonmelanoma skin cancer), testicles, and
uterus. Association between sarcoidosis and benign or malignant lesions of the female gonad seems
to be extremely rare. To our knowledge, our second case is the first to be described in the literature with
concurrent sarcoidosis and ovarian teratoma.
Conclusion: Intraabdominal sarcoidosis is a very rare affection. However, it should be considered as a
differential diagnosis in patients presenting with intraabdominal tumor mass or lymphadenopathy, since
it may substantially influence the treatment strategy.
P 35
Minimalinvasives, retroperitoneales Debridement und Drainage bei nekrotisierender Pankreatitis
D.O. Weber, A. Imhof, B. Boldog, P. Soyka, W. Schweizer (Schaffhausen)
Objective: Die akute Pankreatitis ist oft selbstlimitierend. In etwa einem Fünftel der Fälle entwickelt sich
daraus das Bild einer nekrotisierenden Pankreatitis. Die optimale Therapie wird nach wie vor kontrovers
diskutiert. Neben konservativ-antibiotischen Therapien sind beim chirurgischen Vorgehen Kriterien wie
Invasivität, Zugänglichkeit und Effektivität entscheidend. Ein minimalinvasiver retroperitonealer Zugang
bietet den Vorteil eines schonenden und dennoch übersichtlichen Zugangs ohne Eröffnung des Peritoneums. Wir berichten über unsere Erfahrung bei vier Patienten.
Methods: Retrospektive Analyse der Falldaten von vier Patienten.
Results: Bei zwei Patienten war die Ursache der nekrotisierenden Pankreatitis biliär bedingt, bei einem
Patienten durch ein chronisch penetrierendes Duodenalulcus und bei einer weiblichen Patientin äthylisch. Das mittlere Alter zum Zeitpunkt des Eingriffs betrug 52 Jahre. Alle Patienten zeigten klinisch ein
septisches Zustandsbild und in den CT-Untersuchungen retroperitoneale Abszesse mit Nekrosestrassen.
70
Im Fall der weiblichen Patientin bestand die Therapie ausschließlich in der radiologischen Einlage eines
retroperitonealen Spülkatheters. Bei den weiteren der bekannten Fälle wurde ein Debridement durch einen
retroperitonealen Zugang vorgenommen und Spülkatheter eingelegt. Alle Patienten überlebten obwohl
es während der Hospitalisation zu üblichen Komplikationen kam. In einem Fall kam es zu Nekrosen im
Bereich des Zuganges, zu einer Kolonleckage mit Peritonitis und der Notwendigkeit zur Laparotomie,
einem Platzbauch sowie einer Pankreasfistel. In einem Fall kam es zu einer Durchwanderungspleuritis
mit Sepsis. In einem Fall entwickelte sich während der Hospitalisation eine Pneumonie. In einem Fall kam
es zu abdominalen Komplikationen mit offener Abdominalbehandlung bei Bauchwanddehiszenz aber
gutem Outcome.
Conclusion: Die nekrotisierende Pankreatitis ist ein schwerwiegendes Krankheitsbild. Aussagekräftige,
vergleichende Fallzahlen zu den verschiedenen Therapiemethoden liegen nicht vor. Es scheint, dass es
unabhängig von der gewählten Methode der chirurgischen Therapie keine wesentlichen Unterschiede
bei der Morbidität gibt. Die Mortalität ist aber mit bis zu 50% enorm hoch. Unseres Erachtens vereinigt die
retroperitoneale Zugangsweise die Vorteile einer chirurgischen Sanierung (effektive Nekrosektomie und
Debridement) mit dem möglichen Vorteil der Erhaltung der peritonealen Barriere.
P 36
Akutes Abdomen durch inkarzeriertes Dünndarmdivertikel unter dem Ligamentum Treitz
A. Imhof, W. Schweizer (Schaffhausen)
Objective: Dünndarmdivertikel sind insgesamt selten und machen 0,1-1,4% der gastrointestinalen Divertikel aus. Komplikationen treten aber in 6-13% der Fälle auf, bei betagten Patienten mit einer Letalität von
bis zu 40%. Die häufigsten Komplikationen sind Divertikulitiden und Perforationen mit 7%, akute Passagebehinderungen durch Briden, Volvuli oder Invaginationen treten in 3% auf, zu Hämorrhagien kommt es in
2-7%. Selten sind makrozytäre Anämien durch chronische Resorptionsstörugen mit Malabsorption.
Methods: Fallbeschreibung
Results: 76-jährige, subfebrile Patientin in reduziertem Allgemeinzustand. Keine abdominellen Voroperationen. Seit 48 Stunden initial epigastrische Schmerzen von dauerhaftem Charakter, welche ohne klare
Beziehung zur Nahrungsaufnahme plötzlich aufgetreten sind und seither an Stärke zunehmen. Schmerzverlagerung gegen den Unterbauch. Nausea, Vomitus. Klinisch geblähtes Abdomen mit regen, normalgestellten Darmgeräuschen. Druckdolenz über allen vier Quadranten mit peritonitischer Abwehrspannung
im Unterbauch beidseits. Leukozytose von 21‘000/mm3, CRP 248 mg/l. Konventionell radiologisch Ausschluss freier Luft in abdomine. Sonographisch reizlose Divertikulose des Colon sigmoideum. Computertomographisch dringender Verdacht einer Treitz‘schen Hernie mit lokoregionärer Entzündungsreaktion
ohne Perforation oder Abszedierung. Diagnostische Laparoskopie: Die erste Jejunumschlinge ist gegen
das Lig. Treitz umgeschlagen und darunter inkarzeriert, nach Mobilisation dieser Schlinge zeigt diese ein
4 cm grosses, entzündlich verändertes Dünndarmdivertikel antimesenterial ante perforationem. Es folgt
die Dünndarmsegmentresektion. Der postoperative Verlauf gestaltet sich komplikationslos.
Conclusion: Dünndarmdivertikel sind selten und meist asymptomatisch. Frauen mittleren Alters sind
bevorzugt betroffen, die Divetikel können kongenital vorliegen oder erworben sein. Die Divertikulose des
Dünndarms wird erst mit dem Auftreten von Komplikationen klinisch relevant und zeigt dann eine vielfältige und uncharakteristische Symptomatik. Die Komplikationen reichen von der entzündlichen, konservativ behandelbaren Reaktion über akute Passagestörungen bis hin zur lebensbedrohlichen Perforation
oder Hämorrhagie.
P 37
Primäre aorto-duodenale Fistel: eine seltene, aber schwerwiegende Ursache für eine obere gastrointestinale Blutung
A. Oesch1, P. Müller2, H. Würsten1, U. Laffer1 (1Biel, 2Bern)
Objective: Gastrointestinale Blutungen sind ein häufiges Problem auf der Notfallstation. Die Ursachen
sind meistens mittels Endoskopie zu identifizieren. Viel seltener und schwieriger zu diagnostizieren sind
Blutungen aus einer primären aorto-intestinalen Fistel. Eine verzögerte Diagnosestellung kann wie im vorliegenden Fall zu tragischen Folgen führen.
Methods: Beim vorliegenden Fall handelt es sich um einen 61-jährigen Patienten, der wegen seit ca. vier
Monaten rezidivierender oberer gastrointestinaler Blutung eingewiesen wurde. Die Aetiologie der Blutung
konnte trotz weitreichender Untersuchungen und viermaliger Hospitalisation in verschiedenen Spitälern
bisher nicht gestellt werden. In den wiederholten Gastroskopien zeigten sich unterschiedliche Pathologien von Refluxoesophagitis über eine erosive Gastritis, Mallory-Weiss Läsionen und einmalig auch ein
Verdacht auf ein Ulcus Dieulafoy. Keine dieser Vermutungsdiagnosen erklärten jedoch die wiederholten
Hb-aktiven Blutungen. Eine Kapselendoskopie war unauffällig und die Angio-CT zeigte neben einer Aortenektasie von 35 mm normale Verhältnisse. Bei Eintritt wurde eine erneute Gastroskopie durchgeführt,
welche ein Blutgerinnsel im Duodenum und nach Anspülen einen fraglichen Gefäss-Stumpf ohne aktive
Blutung zeigte. Die Stelle wurde mit Adrenalin unterspritzt, geclippt und der Patient zur Ueberwachung
stationär aufgenommen. Nach 48 Stunden trat eine erneute, diesmal schockierende Blutung auf, weshalb die Indikation zu einer notfallmässigen explorativen Laparotomie gestellt wurde. Intraoperativ fand
sich eine aorto-duodenale Fistel in Bereiche der Pars III. Nachdem die Blutung mittels Ballonkatheter unter
Kontrolle gebracht wurde, entwickelte der Patient jedoch eine Asystolie und verstarb trotz sofortiger Reanimationsmassnahmen.
Results: Aorto-enterale Fisteln verursachen ca. 0,3% aller oberen gastrointestinalen Blutungen und
weisen eine Mortalität von 20-50% auf. Meistens handelt es sich um sekundäre Fisteln bei einer vaskulären Prothese. Primäre Fisteln sind viel seltener und werden bei Aortenaneurysmata, -dissektionen
oder -entzündungen beschrieben. In 3/4 der Fälle handelt es sich um Aorto-duodenale Fisteln distal der
Pars II. Aortooesophageale Fistel bilden 10 % der Fälle. Aortogastrische Fistel sind eine Rarität. Das erste
Symptom ist in 80% der Fälle eine akute gastrointestinale Hämorrhagie meistens verbunden mit Melaena.
Zusätzlich können abdominale Schmerzen und Zeichen eines Infektes vorkommen. Nach einer ersten
Episode kommt es meist zu erneuten, oft schockierenden Blutungen. Die Diagnose kann gastroskopisch,
angiographisch oder mittels Angio-CT abhängig von der Stabilität des Patienten gestellt werden. Die En-
doskopie ist die Untersuchung der Wahl, da die Quelle direkt gesichtet werden kann. Eine unauffällige
Gastroskopie schliesst die Diagnose aber nicht aus. Gelegentlich wird die Diagnose aber erst wie in
unserem Fall durch eine explorative Laparotomie gestellt. Eine frühzeitige (Verdachts-) Diagnose und Behandlung ist enorm wichtig. Die Therapie besteht durch Uebernähen der Duodenumleckage (ev. Anlage
einer Roux-Schlinge) und Ausschaltung des Aneurysmas durch Implantation einer Rohrprothese.
Conclusion: Bei massiver GI-Blutung und Vorliegen eines Aortenaneurysma muss an das Vorliegen einer
aortointestinalen Fistel gedacht werden.
P 38
Uncomplicated diverticulitis of the transverse colon in a very young female patient
E.K. Drescher, M. Menth, J. Michel, B. Egger (Fribourg)
Objective: Prevalence of diverticular disease increases with age, from less than 10% in patients younger
than 40 years to 55-66% in patients older than 80 years. However, diverticulitis has too long been regarded just as a disease of the elderly.
Methods: We report the case of a 20-year old female patient who presented with acute epigastric abdominal pain lasting for about 24 hours. Personal history was uneventful. At clinical examination there
was a marked tenderness of the right upper abdomen without signs of peritonitis. No fever and no other
pathology. Laboratory results revealed an inflammatory syndrome with a white cell count of 13,1G/l and
a CRP of 84mg/l.
Results: For diagnostic reasons an abdominal CT-scan was performed which showed a thickened transverse colon with surrounding fat alteration and a colonic diverticulum and the diagnosis of a non complicated acute transverse colon diverticulitis was made. Additional diverticula were detected in the right but
not the left colon. A conservative treatment with bowel rest and antibiotics was performed with complete
recovery and an uneventful follow-up until to date (12 month).
Conclusion: Diverticulitis of the transverse colon is a rare disorder. Review of the English literature disclosed just 35 cases of transverse colon diverticulitis. It occurs more often in younger patients and they are
more likely to be male and obese. They often have atypical presentations with a confusing pain pattern
as right epigastric or right lower quadrant pain. Not surprisingly, the condition is often misdiagnosed,
resulting in unnecessary surgery. An abdominal CT scan is the modality of choice for correct diagnosis.
In younger patients with atypical abdominal pain, fever and an inflammatory syndrome the most important diagnostic step is to include diverticulitis (of the transverse or right-sided colon) in the differential
diagnosis. Even in very young patients medical therapy with bowel rest and antibiotics is appropriate and
successful for transverse colon diverticulitis when free perforation and peritoneal signs are absent and
the inflammation is contained, as shown by computerized tomography. Operative exploration should be
reserved for patients with diffuse peritonitis or those where perforated colon cancer cannot be excluded.
P 39
Arterio-venous fistula of the external iliac vessels: a rare cause of massive lower gastrointestinal bleeding
P. Froment, H.M. Hoogewoud, S. Martin, M. Menth, J. Michel, B. Egger (Fribourg)
Objective: We report herein the case of a patient with three episodes of massive rectal bleeding due to an
arterio-venous fistula managed with embolization and stenting.
Objective: Acute lower gastrointestinal bleeding may be a diagnostic challenge for physicians and surgeons. Gastro-duodenoscopy, colonoscopy and angiography are established tools to localize and eventually treat the bleeding source. We report herein the case of a patient with three episodes of massive rectal bleeding due to an arterio-venous fistula of the external iliac vessels which was managed successfully
by angiography with embolization and stenting.
Methods: Case report. A 70-year old man was operated by cysto-prostatectomy with pelvic lymphadenectomy and ureterostomy according to Bricker for a bladder carcinoma pT4N1MxG3. Twenty-eigth days
later he was reoperated because of a small bowel occlusion managed with adhesiolysis, a 40cm small
bowel resection and a split jejuno-ileostoma. Sixty days after the first operation, the patient passed blood
ab ano. Colonoscopy and ileoscopy revealed no source of bleeding. After a second episode of rectal bleeding, selective angiography of the three visceral arteries was still unable to find out the source of bleeding.
After the third episode of massive hematochezia with severe hypotension, repeated angiography discovered a fistula between the left external iliac artery and vein. The left internal iliac artery was embolized and
a covered stent was unfolded in the external iliac artery. Haemostasis was achieved. There was neither
recurrence of bleeding nor ischemic complication. Five months later the patient deceased because of
tumour progression.
Methods: A 70-year old man underwent a cysto-prostatectomy with pelvic lymphadenectomy and ureterostomy according to Bricker for a urinary bladder carcinoma pT4N1MxG3. Twenty-eight days later he
was re-operated because of an ileus and adhesiolysis, partial small bowel resection and a split jejuno-ileostomy were performed. Sixty days after the initial intervention the patient was readmitted due to massive
lower gastrointestinal bleeding. Emergency ileoscopy and colonoscopy revealed no source of bleeding.
After a second episode of rectal bleeding some hours later, selective angiography of the three visceral
arteries was performed but the bleeding source not localized. After the third episode of massive hematochezia with shock, repeated emergency angiography of the aorta demonstrated a fistula between the left
external iliac artery and vein. Haemostasis was finally achieved with embolization of the left internal iliac
artery and stenting of the left external iliac artery at the site of the fistula. The further follow-up was then
uneventful; however, the patient died five months later because of systemic tumour progression.
Results: The most frequent causes of lower gastrointestinal bleeding are diverticulosis, tumours, vascular
malformations and internal haemorrhoids. More rarely bleeding occurs due to portal hypertension, rectal
Dieulafoy or solitary ulcer and inflammatory bowel disease. In this case we have found an arterio-venous
fistula between the external iliac vessels after extensive pelvic surgery. It may be postulated that this fistula
created a local hypertension in the perirectal vein plexus with concomitant rupture and intra-intestinal
bleeding. In the literature no such case has been reported up to date.
Conclusion: After extensive pelvic tumor surgery arterio-venous fistula may occur and lead to local por-
tal hypertension with concomitant lower gastrointestinal bleeding. Such bleeding sources may only be
detected by non-selective angiography.
P 40
Unsuspected ruptured ectopic pregnancy during elective cholecystectomy: a case report
O. Pittet, A. Paroz, N. Demartines (Lausanne)
Objective: Intra-abdominal blood finding during the course of laparoscopic cholecystectomy is mainly of
iatrogenic origin but another source of bleeding should not be missed. We hereby report the case of a patient who had an elective laparoscopic cholecystectomy during which an asymptomatic ectopic ruptured
pregnancy was discovered.
Methods: Case-Report of a rarity.
Results: A 26 years old woman consulted the emergency department for upper right abdominal pain.
Diagnosis of symptomatic cholelithiasis was confirmed by ultrasound and elective laparoscopic cholecystectomy planned 1 month later. At the introduction of the camera, a small amount of blood was noticed above the omentum and along the right parietocolic gutter, primarily attributed to parietal damage
at introduction of trocars. Cholecystectomy was then performed without complications. At the end of the
procedure however, a complete abdominal status allowed to reveal another 200 ml of blood in the pelvic
cavity associated with dilatation of the right fallopian tube and the presence of haematic clots. Intraoperative urinary pregnancy test was performed and positive, as well as an elevated blood level of b-HCG.
Longitudinal salpingotomy was then performed and allowed the laparoscopic extraction of the embryo
without salpingectomy. Postoperative course was uneventful and the patient discharged at day 2.
Conclusion: The literature reported 21 incidental ectopic pregnancy finding together with acute appendicitis since 1960, but no cases during elective cholecystectomy until the present case. The possibility of
associated pathological disorders should always be considered in the presence of hemoperitoneum during an elective procedure especially laparoscopic. Iatrogenic damage should be an exclusion diagnosis
and a systematic revision of the entire abdominal cavity is mandatory.
P 41
Perforated Meckel’s diverticulitis complicating active Crohn’s ileitis
F. Schwenter, M. Maffei, P. Gervaz, Ph. Morel (Genève)
Objective: The association of ileal Crohn‘s disease and Meckel‘s diverticulum has been previously described, but the extension of the inflammatory process of the ileum into the diverticulum is rare, and very few
patients with Crohn‘s disease will develop complicated Meckel‘s diverticulitis, and require surgery.
Methods: We report herein the case of a 22-year old woman, who was admitted for abdominal pain, fever
and diarrhoea. She was recently diagnosed with ileal Crohn‘s disease, and the CT scan demonstrated
active inflammation of the terminal ileum, as well as a 3x3 cm abscess in the right iliac fossa located at
distance from the appendix, which appeared normal. The initial management included antibiotics, azathioprine and percutaneous CT scan-guided drainage of the abscess. Unfortunately, conservative management proved unsuccessful, and surgery was considered following the development of persistent purulent
drainage from the drain orifice.
Results: Laparoscopy was performed, and revealed, in addition to inflammation of the last 80 cm of
the small bowel, a mass adherent to the anterior abdominal wall. This proved to be a fistulising 3x3 cm
abscess in connection with a large Meckel‘s diverticulum, and it was decided to avoid an extensive ileocecal resection and to only perform Meckel‘s diverticulectomy with an endoGIA stapler; the pathologic
examination of the surgical specimen revealed the presence of an active transmural inflammation with
granulomas and perforation of the diverticulum at its extremity. The postoperative course was uneventful,
and medical treatment of the underlying Crohn‘s disease proved subsequently successful, with clinical
and biological parameters of inflammation returning to normal within 15 days.
Conclusion: In conclusion, this case illustrates how Crohn‘s disease may extend to an adjacent Meckel‘s
diverticulum and be responsible for perforation in this location. In this young patient, this unusual combination was a blessing in disguise, because extensive small bowel resection could be avoided.
P 42
Surgical treatment of right hypochondrium sarcomas
P. Bucher, S. Ostermann, F. Pugin, Ph. Morel (Genève)
Objective: Abdominal sarcomas are infrequent tumors for which surgical treatment represent the only
chance of cure.
Methods: We present two cases of right hypochondrium sarcomas treated surgically in our department in
young male patients (28 and 40 years) and review the surgical implications for the general and visceral
surgeon when facing these tumors.
Results: The first patients presented a proximal transverse colon high grade sarcomas (diameter 12cm)
associated with sepsis due to surinfected tumoral necrosis. Surgical treatment consisted of extended
carcinologic right colectomy associated with cholecystectomy and epiploectomy. The second patient
presented a liposarcoma (diameter 25cm) of the right colon angle mesocolon associated diagnosed
due pain associated with partial tumors necrosis. Surgical treatment consisted of extended carcinologic
right colectomy associated with segmental small bowel resections, atypical hepatectomy, cholecystectomy, epiploectomy and abdominal wall resection. Per-operative surgical margins were examined through
multiple frozen sections in the 2 patients to confirm absence of margins invasion. No post-operative complications were recorded. All patients are alive without recurrence and did not received complementary
treatment according to completeness of surgical resection.
Conclusion: Complete surgical resection is the only chance to cure abdominal sarcomas. When performing surgical resection for these tumors, surgeon should focus on the need for clear surgical margins.
This should be confirmed per-operatively through frozen section analysis. Surgical treatment of abdominal sarcomas may frequently implicate multi-visceral resection. Long term survival can be offered to
patients with abdominal sarcomas in cases of complete surgical resection.
71
P 43
Akute Divertikulitis des rechten Hemikolon
A. Imhof, W. Schweizer (Schaffhausen)
Objective: Die akute Divertikulitis des rechten Hemikolon ist eine in westlichen Ländern selten auftretende
Differentialdiagnose der Appendicitis acuta. Sie tritt in einem Fall auf 300 Appendicitiden auf. Im Vergleich
dazu findet sie sich in asiatischen Ländern häufiger, nämlich in 1:40 bis 1:180 Fällen. Die Diagnose der
Divertikulitis des rechten Hemikolon wird meist erst intraoperativ im Rahmen einer Appendektomie gestellt, die chirurgische Strategie richtet sich nach der Schwere der Entzündung und reicht von der konservativen Therapie der Divertikulitis (mit Appendektomie) über die Divertikulektomie bei kleinen, solitären
Divertikeln mit begrenzter Entzündungsreaktion bis hin zur Ileocoecalresektion oder Hemikolektomie
rechts bei perforierten oder abszedierten Befunden.
Methods: Über 13 Monate fanden wir 2006/2007 vier Patienten mit einer Divertikulitis des Colon ascendens bei Verdacht auf eine Appendicitis acuta. Es wurden in diesem Zeitraum 130 Appendektomien
vorgenommen.
Results: Vier Fälle bei insgesamt 130 Appendektomien entsprechen einer Rate von 3%. Es handelt sich
um zwei Frauen und zwei Männer im Alter zwischen 44-52 Jahren. Bei zwei Patienten führte die Laparoskopie zur richtigen Diagnose: In beiden Fällen wurde zur medianen Laparotomie konvertiert, einmal
für eine Ileocoecalresektion, einmal für eine Hemikolektomie rechts. Bei den zwei anderen Patienten fand
sich im Rahmen der offenen Appendektomie eine blande Appendix vermiformis: Von diesen beiden wurde einmal die Appendektomie und die Exploration des Situs über den Wechselschnitt vorgenommen mit
dem Entscheid, die Divertikulitis konservativ zu behandeln. Im anderen Fall wurde auf eine mediane Laparotomie konvertiert für die folgende erweiterte Ileocoecalresektion. Drei Patienten erholten sich postoperativ ohne weitere Komplikationen, ein Patient wurde bei Entwicklung eines peritonitischen Abdomens nach
erweiterter Ileocoecalresektion relaparotomiert und lavagiert, eine Anastomoseninsuffizienz lag nicht vor.
Auch dieser Patient erholte sich in der Folge ohne weitere Komplikation.
Conclusion: Die Divertikulitis des rechten Hemikolon ist eine seltene Differentialdiagnose der Appendicitis
acuta, welche häufig erst intraoperativ diagnostiziert wird. Bei entzündungsfreier Appendix vermiformis
muss an diese seltene Differentialdiagnose gedacht und die Divertikulitis des rechten Hemikolon gesucht
werden. Die weitere chirurgische Therapie richtet sich nach der Ausdehnung und Schwere der Entzündung.
P 44
fluid but no pneumoperitoneum, a rupture of the urinary bladder should be considered as differential
diagnosis. To what degree an uncommon cause such as impeded micturition, as a potential side-effect of
benzodiazepine abuse, could play a role, remains speculative.
P 46
Is Somatostatin receptor scintigraphy (Octreoscan) a good diagnostic technique in the management of
appendicular carcinoid metastases? – A case report and review of literature
L. Regusci, M. Brenna, G. Peloni, P. Manfrini, F. Fasolini (Mendrisio)
Objective: Carcinoid tumors are rare( 1% of all malignancies), arising from neuroendocrine cells. The majority arise in the gastrointestinal system (GI carcinoids). Diagnosis, prognosis and treatment are based
on biochemical markers and imaging investigations. The prognosis is related mostly to the presence of
metastases and age of the patient. Octreoscan contributes to a better localization of primary tumors and
their metastases which were not detected by conventional imaging.
Methods: We present a case of a 55 years old waman admitted for acute appendicitis. She was submitted to an explorative laparoscopy and appendicectomy.
Results: Result of histological examination revealed 2,1cm in size carcinoid of appendix. The patient was
discharged at 3 days postoperatively without problems. Further investigations (5-HIAA; US) carried out
in the period didn‘t document metastases. In particulary octreoscan was normal. The patient was submitted to right hemicolectomy with locoregional lymphadenectomy . Postoperatives days were without
complications. The histological result of this second operation shows two positives lymphonodes out of
14 in the specimen.
Conclusion: Carcinoid tumors of the appendix, in most cases, are found incidentally during appendicectomies, especially in young females, and usually are less than 1cm in size, which is probably the reason
for the absence of metastases in the majority of theses cases. New diagnostic and treatment modalities in
metastatic carcinoid patients may result in a better quality of life and a longer survival. Despite Octreoscan
sensivity of 95% in the literature, in our case octreoscan was unhelpful, especially in this borderline tumor
(2,1cm in size). So decision making in favour of hemicolectomy was based only on the size of the carcinoid. Anyway somatostatin receptor scintigraphy improves tumor detection, has major clinical significance
and should be performed systematically for staging and therapeutic decision making in patients with
gastrointestinal tumors. Negative octreoscan does not exclude presence of further disease.
Giant liver hemangioma causing postprandial abdominal pain. A case report and review of the literature
C. Bach, V. Schreiber, R. Schlumpf (Aarau)
P 47
Objective: Hemangioma is the most common benign tumor of the liver. The majority of these tumors are
asymptomatic and usually diagnosed incidentally by sonography or CT scan. If symptomatic surgery is
the treatment of choice. We report a case of a patient with a giant, symptomatic hemangioma. The clinical
presentation and radiological findings and intraoperative findings are presented. A review of literature is
given.
Methods: Case report: 46-year-old woman whose hemangioma was incidentally detected by ultrasound
during a clarification of anemia 13 years ago. Follow up examinations showed an enlargement. The hemangioma in the left lobe had a maximum diameter of 16 cm. CT scan also showed a compression of the
hilus structures, liver veins, stomach and pancreas. Another hemangioma with a diameter of 3 cm was
found in segment VII. In the meantime the patient complained of postprandial abdominal pain. Because of
the giant size with a high risk of rupture also due to minor abdominal trauma and the patient`s discomfort
we performed an atypical resection of the left liver lobe and of segment VII as well as a cholecystectomy.
Results: The postoperative period was without any complications. Histology confirmed a cavernous hemangioma. Demission was 9 days after operation. 6 weeks postoperative she was free of pain without
analgetics.
Conclusion: According to literature management of hemangioma is still controversial. Mandatory surgical indications are traumatic or spontaneous rupture, intratumoral bleeding or thrombosis, consumptive
coagulopathy and rapid growth. Relative indications are persistent abdominal pain, portal hypertension,
superficial localization (risk of traumatic perforation) and an uncertain diagnosis. If therapy is necessary,
treatment of choice is either resection or enucleation. Alternative therapies are embolization, hepatic artery ligation, radiation therapy and corticosteroids. These are often not successful.
Objective: Desmoid type fibromatosis is a rare mesenchymal tumor characterized by highly aggressive
local invasion. It is most frequently localized in the chest wall, head/neck area, shoulder and abdominal
wall. Complete excision is the treatment of choice. However, due to the local aggressiveness of this tumor
this is often difficult and there is a high recurrence rate after surgical excision especially if no free margins
are obtained during a wide resection of the tumor.
Methods: We describe a rare case of abdominal wall fibromatosis after appendectomy in childhood. By
wide resection of the tumor in the abdominal wall, hemicolectomy and partial resection of the omentum,
complete removal of the tumor mass with negative surgical margins could be achieved. For reconstruction of the abdominal wall, implantation of a polypropylene net was used.
Results: On follow up six and nine months after surgery there was no evidence of recurrent disease clinically and on ultrasound.
Conclusion: We present an unusual case of abdominal fibromatosis in a male adolescent following
appendectomy. The patient was treated by wide excisional surgery and abdominal wall reconstruction
using a polypropylene net. In conclusion, wide surgical resection and tumor-free margins of the resected
specimen remain the main treatment goals for aggressive fibromatosis in children. In addition, adjuvant
therapies are of growing importance and should be further investigated.
P 45
Recurrent rupture of the urinary bladder: leaving the beaten track in differential diagnosis of the acute
abdomen
B.M. Wilmink, M. Kocher, A. Huber (Bruderholz)
Objective: A spontaneous rupture of the urinary bladder is a rare condition. Reviewing current literature,
it is mainly described in coincidence with pelvic radiation, alcohol abuse or neurogenic bladder dysfunction.
Methods: We report the case of a 78-year-old woman who suffered from spontaneous bladder rupture
twice within one and a half years. Both times she presented to our emergency department with complaints of weakness, sudden onset of abdominal pain and clinical evidence for peritonism. Her medical
history contained a Billroth-II-procedure in 1991 due to gastric cancer and a diverticular resection of the
urinary bladder two years earlier, due to recurrent episodes of cystitis. Her husband`s report also suggested chronic benzodiazepine abuse. CT-scans respectively showed a lot of free intraabdominal fluid
without subsumable pathology.
Results: Both times laparotomy revealed a perforation of the urinary bladder. The defect was excised
and closed by a double-row-suture. The patient made an uneventful recovery. Histological examination
showed chronic inflammation and fibrosis of the cystic wall with no signs of malignancy.
Conclusion: In patients with acute abdominal conditions, radiologically confirmed free intraabdominal
72
Abdominal wall fibromatosis after appendectomy: a case report of a 14-year old boy
S. Habelt, M. Köhler, D. Schäfer, E. Bruder, J. Mayr (Basel)
P 48
Colonic endometriosis and exeptionnal association with thrombocytopenic thrombotic purpura
W. Oulhaci, T. Nicolet, A. Genton, A. Blaser (Nyon)
Objective: A case report Background Endometriosis of the digestive tract is rare and affects the rectum
or sigmoid colon in 6 to 30% of cases. It may mimic digestive tumors, chronic inflammatory bowel diseases and diverticulitis. Thrombocytopenic thrombotic purpura (TTP) is an acute syndrome related to
the hemolytic-uremic syndome and comprises thrombocytopenia, microangiopathic hemolytic anemia
and acute renal failure.
Methods: Case A 25 year-old nulliparous woman have acute symptoms related to a sigmoid stricture
due to pseudo-tumoral endometriosis, and underwent sigmoid resection. Typical TTP started on the first
postoperative day, and required intensive care admission, glucorticosteroids, plasmapheresis and hemofiltration. A complete diagnostic workup revealed no known etiologies for TTP.
Results: no results because of a case report
Conclusion: Discussion To our knowledge, this is the first description of colonic endometriosis associated
with TTP. Since no other known factors associated with TTP were present in this case, the operation might
have been the triggering event, suggesting that TTP might be triggered by bioactve products released by
wounded endometriotic tissue. Further studies are needed to explore the association between endometriosis and TTP.
P 49
P 52
Invagination eine seltene DD beim akuten Abdomen des Erwachsenen
A. Donadini, C. Ruzza, C. Marazzi, J. Peltzer (Delémont)
Seltene Ursache eines Kolonileus bei einem 20-Jährigen
C. Fuchs, C. Hueber, A. Bissat, R. Schlumpf (Aarau)
Objective: Intussusception ist die Invagination eines Darmsegmentes welche beim Kleinkind häufig zur
DD des akuten Abdomens gehört. Beim Erwachsenen hingegen ist sie nur in 1 bis 5 % aller Darmobstruktionen zu finden und deshalb häufig verpasst. Als Ursachen finden sich in 90% voluminöse intraluminale
Tumoren wie Adenokarzinome des Kolons, Leiomyosarkome des Dünndarmes, Polypen oder Lipome, die
durch die Darmperistaltik weiter transportiert werden und die Invagination bewirken. Postoperative Adherenzen, Anastomosen sowie Darmsonden sind für die restlichen 10% verantwortlich. Klinisch findet sich
meist ein subakuter oder chronischer Verlauf mit repetitiven zum Teil persistierenden Schmerzen die bis
zum akuten mechanischen Ileus führen. Die Abdomen-CT-Untersuchung ist das Mittel der Wahl die uns
neben der Diagnostik Informationen zur Dignität und Operationsplanung gibt. Die Therapie richtet sich
nach Befund wobei jedoch eine Darmresektion meist unvermeidbar ist. Laparoskopische und minimal
invasive Techniken sind möglich und empfehlenswert.
Methods: Im Zeitlauf eines Jahres wurden zwei Patienten mit akuter Klinik der Invagination operiert. Bei
dem 48 jährigen Patienten führte ein 7 cm grosses Lipom im Coecalbereich zu einer ileocoecalen Invagination die einer Hemikolektomie rechts bedurfte. Bei der 62 jährigen Patientin bewirkte ein 6cm grosser
gestielter Polyp im Ileum eine Dünndarminvagination von 40cm die zu einer Dünndarmresektion führte.
Die Hemikolektomie wurde über eine mediane Laparotomie durchgeführt, während die Dünndarmresektion laparoskopisch assistiert über eine Minilaparotomie beendet werden konnte.
Results: Beide Patienten zeigten postoperativ ein komplikationsloser Verlauf.
Conclusion: Die Invagination beim Erwachsenen bleibt ein häufig über längere Zeit verpasstes Krankheitsbild. Die Therapie der Wahl bleibt die operative Exploration mit Resektion des betroffenen Darmsegmentes. Beim Kolon finden sich in 60% beim Dünndarm in 30% maligne Tumoren die onkologisch radikal
operiert werden sollen. Laparoskopische sowie minimale Zugänge scheinen in der aktuellen Literatur
vorteilhaft zu sein.
Objective: Fallbericht einer seltenen Ursache eins Kolonileus bei einem 20-Jährigen.
Methods: Fall: Ein 20-jähriger Patient wurde von einem peripheren Spital mit der Diagnose eines Kolonileus überwiesen. Der Patient berichtete, seit 4 Tagen an krampfartigen, linksseitigen Oberbauchschmerzen
zu leiden, begleitet von Übelkeit. Er musste einmalig erbrechen. Der letzte Stuhlgang war vor 4 Tagen. Eine
ähnliche Schmerzepisode hatte er bereits vor zirka 5 Monaten gehabt mit spontaner Regredienz der Beschwerden. Es lagen keine abdominalen Voroperationen oder ein Status nach Abdominaltrauma vor. Klinisch zeigte sich auf der Notfallstation ein gespanntes, diffus druckdolentes Abdomen ohne Peritonismus
und mit spärlichen Darmgeräuschen. Im Labor fanden sich Leukozyten von 10,1 G/l und ein CRP von 13
mg/l. Im auswärtig durchgeführten Computertomogramm (CT) des Abdomens zeigte sich ein Kolonileus
bei Inkarzeration der linken Kolonflexur in einer Zwerchfelllücke, lateral der Milz. Aufgrund des Kolonileus
stellten wir die Indikation zur Laparotomie. Intraoperativ zeigte sich, dass die linke Kolonflexur, inklusive
Omentum majus, in einer zirka 3 cm grossen posterolateralen Zwerchfelllücke im Thorax gefangen war.
Nach Erweiterung der Lücke gelang es, das Kolon zu reponieren. Die Bruchlücke wurde mit einer Naht
verschlossen. Am Ende der Operation wurde eine Thoraxdrainage links eingelegt.
Results: Im genannten Fall war eine Bochdalek-Hernie die Ursache des Kolonileus. Die Diagnose konnte
mittels CT gestellt werden. Die linke Kolonflexur als Bruchinhalt konnte nach minimaler Erweiterung der
Bruchlücke problemlos reponiert werden. Der Bruchlückenverschluss gelang spannungsfrei mit einer
Naht. Der postoperative Verlauf war komplikationslos.
Conclusion: Eine inkarzerierte, extrahiatale Zwerchfellhernie kann einen Kolonileus verursachen. Ein unvollständiger Verschluss des Diaphragmas in der 7.-8. Embryonalwoche führt zu einer Zwerchfelllücke. Im
Falle der Bochdalek-Hernie liegen die meist grossen Defekte posterolateral links, im Trigonum lumbocostale. Sie ist die häufigste Zwerchfellhernie beim Neugeborenen und stellt aufgrund pulmonaler Probleme
eine ernsthafte Erkrankung mit hoher Letalität dar. Im Erwachsenenalter werden kleine Bochdalek-Hernien in CT-Serien in bis zu 6% nachgewiesen, führen aber sehr selten zu Notfällen. In der Literatur sind
nur wenige Fälle beschrieben. Als Symptome verursachen solche Hernien vorwiegend gastrointestinale
Beschwerden und Thoraxschmerzen. Die Diagnose kann im CT gestellt werden. Die operative Versorgung erfolgt mittels Thorako-und/oder Laparoskopie oder Laparotomie. Der Bruchlückenverschluss kann
stoss-auf-stoss oder mit einem Kunststoffnetz erfolgen.
P 50
Adenocarcinoma arising in a retrorectal tailgut cyst: case report and review
M. Maternini, E. Pezzetta, O. Martinet (Montreux)
Objective: To show a rare case of malignant transformation of a uncommon congenital lesion.
Methods: A 85-year-old man, previously healthy, presented with a 3 months history of diarrhoea. Sigmoidoscopy revealed a substenostante rectal mass, then with a biopsy, an adenocarcinoma has been found.
The abdominal CT Scan showed bilateral liver metastasis. The patient underwent a complete resection of
the mass through laparotomy with low anterior resection of the rectum.
Results: Gross examination revealed a tumoral mass, white colouring with necrotic zones in the rectal
wall. Microscopically there was an important number of small irregular cysts with diameter up to 9 mm.
An epithelial covering, commonly found in gastrointestinal tract, was present. The morphology of this carcinoma was similar to the usual colonic adenocarcinomas.
Conclusion: Malignant transformation of retro rectal hamartomatous cyst is very rare, at present only 11
cases are reported in the English literature. The disease is more often observed in young female patients.
Our report is interesting because the malignant transformation occurred in an old patient with synchronous liver metastasis.
P 51
Rare cause of dysphagy: well differentiated esophageal wall Liposarcoma
L. Mica1, D. Gianom1, B. Bode2, P. Jaklin1, A. Hollinger1 (2Männedorf, 2Zürich)
Objective: Liposarcoma represents one of the most frequent (10–20%) malignant mesenchymal tumors
in the adult, affecting mostly the soft tissue of extremities, the trunk or the retroperitoneum. This tumor type
occurs exceptionally rarely in the gastrointestinal tract with only few cases described in the literature.
Methods: A 73-year-old male patient was admitted due to weight loss and anorexia. He had chronical
retrosternal pain and postprandial vomiting since four weeks. Concomitantly this patient suffered progredient vascular encephalopathy and macroangiopathy IV caused by an escalated diabetes mellitus
type II (NIDDM) with a HbAIc of 9.3%. Initial endoscopy of the upper gastrointestinal tract showed a mass
obstructing the distal cervical esophagus to the gastroesophageal junction with no mucosal leasons.
Additional esophagography with gastrographin confirmed the findings of a long-distance esophageal
obstruction of unknown origin. A CT scan of the caudal cervical organs to abdominal organs revealed a
heterogenous esophageal mass not directly separable from the esophageal wall. No further neoplasias
were found in the abdomen. A resection at the mucosal level was performed without complications. Following the resection the patient was on parenteral nutrition for 5 days. Recovery was uneventful. 12-week
follow-up showed a patient in an improved nutritional state and again fully socially integrated.
Results: Histopathological examination: Microscopically the tumor was covered by bland squamous epithelium with no dysplasia. The main mass of the polyp consisted of sheaths of adipocytes of variable size
and often hyperchromic, enlarged and pleomorphic nuclei. The adipocytes showed nuclear immunohistochemical positivity in a reaction with antibodies against MDM2 protein and CDK4. No nonlipogenic or
high-grade areas were identified. A diagnosis of a welldifferentiated liposarcoma was done. The resection
margin of the tumor stalk contained tumor tissue. Macroscopy: Intraoperatively the tumor could be easily
separated from the esophageal lumen with no adhesions to the wall. The tumor was proximally attached
to the esophageal wall by a slender stalk (diameter of 1 cm). Resection at the esophageal level was performed by stapler technique. The resected specimen consisted of the tumor and was 20 cm long with a
diameter of 4.5 to 5.5 cm. The mucosal surface of the mass showed no ulcerations or necrosis.
Conclusion: In this case we found a well-differentiated grade I liposarcoma not radically resected. In the
case of our 73-year-old patient we did not exceed adiuvant therapies due to a palliative situation. Our case
is negligible because liposarcomas of the esophagus are extremely rare, but the differential diagnosis of
a liposarcoma should be considered if there is an matching anamnesis.
P 53
Mucinous cystic neoplasms: different clinical presentations
R.F. Stärkle, C. Buchli, H. Frick, P. Villiger (Chur)
Objective: Mucinous cystic neoplasms are an entity reported with increasing frequency in the literature.
Typically, these lesions are found in the pancreas, but they can also be located in the retroperitoneum and
the hepatobiliary tree. We report different clinical presentations of mucinous cystic neoplasms of the extra
genital location in five women.
Methods: Between August 2006 and September 2007 five women with a mean age of 48 years (23 - 64
years) were treated for mucinous cystic neoplasms of the pancreas and the retroperitoneum.
Results: The clinical presentation and duration of symptoms were quite different in all cases. All patients
were treated by radical resection of their tumor. The women had an uneventful postoperative recovery. The
histopathological examination revealed a cystadenoma in one case, a borderline tumor in three cases
and a cystadenocarcinoma in one case. The typically “ovarian-type” stroma of the mucinous cystic neoplasm was detected in all pathological preparations.
Conclusion: Despite the probably common embryologic origin of cystic mucinous neoplasms, their location can differ, and the symptoms at presentation hence depend mostly on their size. An aggressive
surgical approach with removal of the lesion is recommended, since the severity of the lesion can only be
appreciated by complete histopathological examination.
P 71
Hypoxia activates PKR (dsRNA activated protein kinase) in a HIF1 independant manner
V. Roh, D. Stroka, A. Laemmle, D. Candinas, S. Vorburger (Bern)
Objective: Low oxygen tension, also named hypoxia, is a common feature among tumors. Solid tumors
exhibit hypoxic areas that are difficult to target by conventional therapies. Cells challenged by hypoxia
tend to restore the oxygen tension by stabilizing the alpha subunit of the hypoxia inducible factor 1 (HIF1).
As a consequence, HIF1 up-regulates target genes inducing angiogenesis or anaeorobic metabolism.
Activation of the interferon-inducible, double stranded RNA activated protein kinase PKR leads to inhibition
of cellular as well as viral protein synthesis, growth suppression and apoptosis. PKR activity is dependent
on its dimerization and subsequent autophosphorylation, which is known to be regulated in two major
pathways. On the one hand, the transcription factor E2F-1 or interferons can increase the transcription
of PKR mRNA, leading to a rise of PKR protein levels, therefore facilitating PKR dimerization. On the other
hand, dsRNA or heparin can directly bind to and drive the dimerization and subsequent activation of PKR.
Hypoxia has been shown to be responsible for the activation of kinases such as PKC or p38 MAPK. Therefore we assessed the effect of hypoxia on PKR activation in vitro
Methods: To check whether hypoxia could modulate PKR, we grew cells under 1.5% oxygen, and used
E2F-1 overexpression as a control for PKR upregulation and activation. Quantitative PCR and immunoblotting were performed to investigate the levels of PKR mRNA and protein.
Results: Quantitative PCR and immunoblotting showed that after 24 hours under hypoxia, PKR protein
and mRNA levels remained unaffected, whereby phosphorylation of PKR occurred, suggesting a direct
activation of PKR by hypoxia. Using the HIF1alpha stabilizer DMOG, we could show that activation of PKR
by hypoxia was not dependent on HIF1alpha.
Conclusion: This is the first study reporting PKR activation by hypoxia. These results let us speculate that
targeting PKR in hypoxic tumors could be an efficient strategy to enhance the anti-tumor effect of conventional therapies
73
P 72
Lokalisation schmerzhafter arthrotischer Fussgelenke mittels 99mTc-DPD-SPECT-CT
M. Wiewiorski, M. Kretzschmar, M. Horisberger, H. Rasch, D. Bilecen, A.L. Jacob, V. Valderrabano (Basel)
Objective: Die klinische Lokalisation der Schmerzquelle bei schmerzhaften, degenerativen Veränderungen an Fussgelenken ist kompliziert. Grund dafür ist die komplexe Fussanatomie, die mit zahlreichen
knöchernen und nicht-knöchernen Strukturen aufwartet, die allesamt zum Schmerzempfinden beitragen
können. Nicht-invasive Bildgebungsmethoden (Rx, CT, MRI) zeigen eine schlechte Korrelation zwischen
Schmerzgrad und Ausmass der morphologischen Veränderungen. Die funktionelle Bildgebung mittels
Szintigraphie mit 99mTc-Dicarboxypropandiphosphat (DPD) zeigt gute Ergebnisse bezüglich Detektion schmerzhafter Facettengelenke. Bisher ist diese Methode jedoch nicht bei arthrotisch veränderten
Fussgelenken zum Einsatz gekommen. Zusätzlich ist die diagnostische Genauigkeit durch die geringe
räumliche Auflösung der Szintigraphie eingeschränkt. Single Photon Emission Computed Tomography
– Computed Tomography (SPECT-CT) ist eine neuartige Hybridtechnik, die eine exakte Zuordnung der
metabolischen Information zur anatomischen Struktur erlaubt. Wir hypothetisieren, dass die diagnostische Infiltration eines Mittel- oder Rückfussgelenkes, welches erhöhten 99mTc-DPD-Uptake im SPECT-CT
zeigt, zur Schmerzauflösung führt.
Methods: Eingeschlossen wurden 26 Patienten mit chronischen Schmerzen und radiologischen Zeichen
der Arthrose von Mittel- oder Rückfussgelenken (27 Füsse). Planare Röntgenaufnahmen wurden zum
Auschluss anderer schmerzinduzierender Erkrankungen durchgeführt. Der Schmerzstatus wurde mittels
der Visuellen Analog Skala (VAS) erfasst. Der AOFAS hindfoot/midfoot Score und der SF-36-Score wurden
dokumentiert. Alle Patienten unterzogen sich einer Untersuchung mittels 99mTc-DPD SPECT-CT (Symbia
T2, Siemens, Erlangen). Die Lokalisation des 99mTc-DPD-Uptakes und somit das zu infiltrierende Gelenk
wurden bestimmt. Die Infiltration wurde mit Lokalanästhetikum (Bupivacain) und Iod-Kontrastmittel unter
CT-Durchleuchtung durchgeführt. Die exakte Lage des Kontrastmittels wurde erfasst. Der VAS-Wert wurde
unmittelbar vor und nach der Infiltration notiert. Als erfolgreiche Schmerzauflösung wurde das Absinken
des VAS-Wertes auf <50% des ursprünglichen Wertes definiert. Die partielle Schmerzauflösung als Absinken des VAS-Wertes auf >50% des ursprünglichen Wertes.
Results: Die Infiltration wurde an 26 Rückfuss- und 5 Mittelfussgelenken durchgeführt, wie durch den
99mTc-DPD-Uptake im SPECT-CT angezeigt. Die CT-Kontroll-Untersuchung zeigte ein Kontrastmittel-Depot
und somit eine technisch erfolgreiche Infiltration in allen infiltrierten Gelenken. Bei 22 Patienten zeigte sich
unmittelbar postinterventionell eine signifikante Schmerzauflösung (p<0.001) auf <50% des Ausgangwertes. VAS Mittelwert vor Infiltration betrug 5.77 (range 2-10; SD 2.22 ) und sofort nach Infiltration 0.82
(range 0-4; SD 1.26). Bei drei Patienten zeigte sich eine partielle und bei einem keine Schmerzauflösung.
Conclusion: Die Resultate dieser Studie zeigen eine signifikante Korrelation zwischen Uptake im SPECT-CT
und Schmerzauflösung nach diagnostischer Infiltration. Das SPECT-CT erlaubt die Lokalisation schmerzinduzierender arthrotischer Fussgelenke und liefert wichtige Informationen zur präoperativen Planung.
P 73
Prevalence of sacral dysmorphia in a trauma population; implications for a safe surgical corridor. – A
prospective study
E.A. Hasenböhler, A.E. Williams, J.T. Newman, S.J. Morgan, W.R. Smith, P.F. Stahel (Denver/US)
Objective: Inaccurate sacro-iliac (SI) screw placement in pelvic injured, is a common complication that
can occur despite apparent appropriate positioning on fluoroscopy. The purpose of our study was to define a safe surgical corridor for S1 and S2 SI screw placement, and to describe the prevalence of sacral
dysmorphia in a representative trauma population
Methods: Patients, with a pelvic CT, between January and September 2007, as part of their trauma evaluation, were prospectively included in the study. The axial, coronal and sagittal 2.5 mm CT-views were used
to measure the surgical angles and the widest and narrowest space between the S1 and S2 foramina.
These measurements were then used to define the average surgical corridor of the S1 and S2 body. Furthermore, the axial CT was evaluated to identify the prevalence of sacral dysmorphia.
Results: 344 consecutive patients (245 males and 99 females) were evaluated (mean age 36.9 years
males and 36.8 years females). Significant differences by gender were seen for all S1 and S2 measurements in the axial, coronal and sagittal surgical space, with females having lower values (p<0.01 for all).
A smaller value for females was also discovered for the mean axial and coronal surgical S1 and S2 angle
(p<0.01 for all). A 14.5% prevalence (n=49) for sacral dysmorphia was ascertained. Influence on the safe
surgical corridor was noticed for the axial and coronal angle, for the axial and sagittal S1 corridor, and for
the tallest coronal S1 body height (p<0.01 for all).
Conclusion: A significantly smaller surgical canal was found among females for both S1 and S2 sacral
bodies. The high prevalence of sacral dysmorphia influenced the safe surgical corridor in our trauma population. A careful analysis of the pelvic CT is recommended to avoid inaccurate SI-joint screw placement
in patients with sacral dysmorphia.
P 74
Measurement of compartment pressure of the rectus sheath during intra-abdominal hypertension: Validation and comparison with established intra-abdominal pressure measurement techniques in a porcine
model
M. Cardell1, E.D.L. Benninger1, M. Lachke2, M. Keel1, O. Trentz1, M.D. Menger2, C. Meier1 (1Zürich, 2HomburgSaar/DE)
Objective: Intra-abdominal pressure (IAP) can be measured in different ways. The indirect measurement
via the intra-vesical pressure (IVP) is currently considered the gold standard in the clinical situation. It
was the aim of the herein presented study to investigate whether the compartment pressure of the rectus
sheath (CPRS) reflects the IAP in the presence of intra-abdominal pressure (IAH) and to compare CPRS
with other established indirect IAP measurement techniques in a porcine model.
Methods: Seven anesthesized and mechanically ventilated domestic pigs (34.8±2.5kg) were examined.
A suprapubic urinary catheter was placed through a short midline laparotomy, the femoral vein was can-
74
nulated for the assessment of femoral vein pressure (FVP) and a venflon was percutaneously placed into
the rectus sheath for CPRS measurement. Beside IAP pressure measurement, pulmonary and hemodynamic parameters were monitored throughout the experiment. By means of CO2 pneumoperitoneum the
IAP was raised up to 30mmHg followed by stepwise decompression. Direct IAP was measured via the
insufflator and the corresponding IVP, FVP and CPRS were recorded.
Results: Stepwise elevation in IAP was associated with a simultaneous increase in CPRS. Accordingly,
abdominal decompression resulted in a simultaneous decrease in CPRS. Bland-Altman analysis comparing direct IAP measurement with correspondent CPRS (bias -0.5mmHg, lower and upper limits of agreement (LLA/ULA) -3.6/2.6mmHg) showed a good agreement for IAP at or above 12mmHg. FVP (bias
-0.3mmHg, LLA/ULA -2.3/1.7mmHg) and IVP (bias 0.4mmHg, LLA/ULA -2.1/3.0mmHg) demonstrated
similar results when compared with direct IAP measurement.
Conclusion: The rectus sheath is exposed to virtually the same pressure as the intra-abdominal organs in
our porcine model. CPRS shows a good agreement for IAP comparable to other established indirect IAP
measurement techniques. Thus, assessment of CPRS may represent an alternative indirect method for
IAP monitoring when IVP is not suitable.
P 75
Characterization of putative cancer stem cells in colorectal carcinoma cell lines
G. Iezzi, C. Giovenzana, X.S. Huber, D. Wendt, G. Spagnoli, I. Martin, M. Heberer, D.M. Frey (Basel)
Objective: Cancer originating cell subpopulations, also known as cancer stem cells (CSC), have been
identified in several malignancies, based on the expression of specific surface markers. Phenotypic characteristics of CSC derived from colorectal cancers (CRC) are still debated. Indeed, their low frequency in
clinical specimens, precludes a comprehensive phenotypic and functional analysis. We have investigated
expression of several surface molecules previously reported as potential CSC markers, including CD133,
CD166 and CD44, on established CRC cell lines. Their correlation with CSC functional features, including
ability to grow in spheroids, low proliferation rate and clonogenic capacity, was also assessed.
Methods: Colo201, Colo205, HCT116, LS174, LS180, SW480 cell lines were analyzed for surface markers
expression by flow cytometry. The ability to growth in spheroids was assessed upon culture on polyHema-coated plastic surfaces and spinner flasks. Proliferation rates were assessed by CFSE-dilution upon
culture in normal flasks (2D) or on polyHema-coated plasticware and collagen-based scaffolds (3D).
Clonogenic capacity was tested by limiting dilution analysis.
Results: CD133 expression was detected on a large majority (up to 90%) of HCT116 and LS174 cells, concomitantly with CD166 expression. In contrast, Colo201, Colo205 and LS180 were almost completely negative for CD133 but homogeneously expressed CD166. Finally, SW480 was negative for both markers.
All cell lines expressed CD44 molecule, although to different extents. CD133 expression positively correlated with the capacity to form spheroids/aggregates upon culture on polyHema-treated flasks or spinner
flasks. Moreover, analysis of proliferation rates of CD133+ cell lines, upon culture in 2D or 3D conditions,
indicated a correlation between high CD133 expression and low proliferation rate. In contrast, no significant association between CD133 expression and clonogenic capacity was found. Interestingly, upon cell
sorting of CD133+ and CD133- cells from the same cell lines, CD133 expression was stably maintained
on positive cells, whereas CD133- cells partially reverted to a CD133+ status. The in vivo tumorigenicity of
CD133+ or CD166+ cells versus their negative counterparts is currently under investigation.
Conclusion: Expression of putative CSC markers is heterogeneous in CRC cell lines and may correlate
with defined functional features. Thus, specific CRC cell lines might serve as model for a precise identification of CSC.
P 76
Cancer initiating cells in mesothelioma?
G. Karoubi, R.A. Schmid, G.L. Carboni, L. Cortes-Dericks, I. Breyer, A.E. Dutly (Bern)
Objective: Mesothelioma is a highly lethal and therapy-resistant malignant neoplasm derived from the
mesothelial cell with a mean survival of 4-12 months after diagnosis. Recent reports have illustrated the
possibility of cancer initiating cells with stem cell like properties in human lung carcinoma cell lines and
animal models of lung cancer. According to the cancer stem cell hypothesis, a cancer initiating cell has
the ability to self renew and give rise to cancer progenitor cells ultimately giving rise to the phenotypically
diverse tumor cell populations. Here we hypothesize that there is a distinct cell population in mesothelioma cell lines and primary cultures with stem cell properties that may potentially be responsible for the
carcinogenesis of the disease.
Methods: NCL_H28 cells were cultured in RPMI media supplemented with 1% antibiotics and 10% FBS.
For cytotoxicity assays, cells were treated with Cisplatin (CDDP) for 24 hours and viability was measured
using a cell proliferation kit. Human lung samples were collected in ice-cold saline and cells were isolated by enzymatic digestion overnight. Cells were cultured, expanded and assessed for OCT4 expression
using flow cytometry.
Results: Our preliminary results demonstrate the presence of a small subpopulation of cells (12.8 ± 2.3
%) with surface expression of OCT4 (a transcription factor fundamental for the maintenance of pluripotency and self renewal in embryonic stem cells) in the NCL_H28 human mesothelioma cell line and primary
mesothelioma cells isolated from patients diagnosed with pleural malignant mesothelioma. In addition
we found that the NCL_H28 OCT4+ cells were more resistant to cytotoxic drugs.
Conclusion: These OCT4+ cells may potentially be involved in the tumorigenesis of mesothelioma.
Despite improved therapeutic strategies, local as well as systemic tumor recurrences are unfortunately
common. Although cytotoxic chemotherapy has been shown to be relatively effective in some tumors it
is unable to destroy all the cancer cells. The cancer cells likely survive due to their increased resistance
to drugs as well as their silent replication. Although the source of carcinogenesis is not well elucidated in
mesothelioma, there may potentially be a significant role for OCT4+ cells. A better understanding of these
cells will lead to novel ideas and approaches to fight cancer.
P 77
Recombinant vaccinia virus expressing CD40 ligand enhances the expansion of CD8+ T cells with a
memory phenotype
C. Feder-Mengus1, W.P. Weber1, N. Raafat1, E. Schultz-Thater1, M. Adamina2, D. Oertli1, M. Heberer1,
G. Spagnoli1, P. Zajac1 (1Basel, 2Toronto/CA)
Objective: We and others have shown in vitro (Marti, 1997; Zajac, 1998) and in vivo (Hodge, 1999), that
co-expression of costimulatory molecules enhances immunogenic capacities of recombinant Vaccinia
virus (rVV) encoding tumor associated antigens (TAA). Furthermore, rVV encoding melanoma TAA, CD80
and CD86 was used in a phase I/II clinical trial (Spagnoli, 2002; Zajac, 2003) resulting in enhanced
specific response to TAA after vaccination. Nevertheless, this response is not sustained over time. In order
to study the capacity of these vectors to provide signals relevant in the generation/maintenance of T cell
response against TAA, we tested a rVV expressing CD40 ligand (CD154rVV). CD154 plays a role in activation of helper-dependent immune responses, is expressed on activated CD4+ T cells, binds to CD40
on APCs leading to APC activation and to an increase in their antigen presentation and immunomodulatory capacities (IL-12, IL-15) (Feder-Mengus, 2005). CD154 plays also a role in generation of T cell memory
(Borrow, 1996; Bourgeois, 2003). CD154rVV may reproduce these mechanisms and thereby optimize
CTL generation and help to maintain immune response overtime.
Methods: Phenotypic characterization of CD8+ T cells cultured with infected monocytes as APC was performed by antibody staining and FACS analysis. Gene expression was evaluated by qRT-PCR.
Results: CD154rVV enhances APC capacity to stimulate specific T cell responses (Feder-Mengus, 2005).
Phenotype of total and Ag specific CD8+ T cells primed in presence of CD154rVV infected APC showed an
increase in CD8+ T cells with Central Memory (CM) phenotype (CD45RA+CCR7+) mainly as compared
to ControlVV. More marked differences were observed for Ag specific CD8+ T cells. Activation of total and
CM CD8+ T cells was enhanced upon priming with CD154rVV as compared to ControlVV as demonstrated by enhanced IL-2 and IFN-g gene expression, and increased IFN-g protein expression. Percentage of
dividing cells with CM phenotype upon CD154rVV triggering was also observed. Among many signals,
VV infection is triggering IL-15 gene expression in APC. In CD154rVV infected cultures, this gene was
expressed to a higher extent.
Conclusion: Taken together, these data indicate that stimulation of CD8+ T cells with CD154rVV increases
expansion of T cells with CM phenotype as compared to ControlVV. Such rVV might help to bypass the requirement for helper cells, thus qualifying as a relevant reagent in the generation of CD8+ T cell responses,
and to maintain immune response overtime during vaccination process in cancer immunotherapy.
P 78
Ten years insulin independence after islet allogeneic transplantation for type 1 diabetes
N. Niclauss1, S. Ferrari-Lacraz1, Ph. Morel1, F. Ris1, L. Bühler1, J. Oberholzer2, J. Philippe1, J. Villard1,
T. Berney1 (1Genève, 2Chicago/US)
Objective: We report herein the first patient to ever reach ten years of insulin independence after allogeneic islet transplantation.
Methods: A 35-year-old female patient with a 27-year history of C-peptide-negative, type 1 diabetes underwent islet transplantation 6 years after kidney transplant. Islet transplantation was motivated by extreme
metabolic lability and severe hypoglycaemia unawareness, on an average daily insulin dose of 16 U. She
received on June 21, 1996 a single intraportal infusion of 8’800 IEQ/kg body weight pooled from 2 cadaveric donors. She was maintained on her immunosuppressive regimen associating cyclosporine, azathioprine and prednisone and received ATG induction. Her current immunosuppressive regimen associates
cyclosporine (100 ng/ml), sodium mycophenolate (180 mg bid) and prednisone (5 mg qd).
Results: A 50% decrease in her daily insulin requirements was obtained by 1 month post-transplant, and
insulin was permanently discontinued by 3 months post-transplant. Hypoglycemic events disappeared
immediately after transplant. She has met ADA criteria for normal fasting glucose and normal glucose
tolerance, assessed by yearly OGTT, from 3 months post-transplant until now. Her latest acute insulin
response after arginine-stimulation was 19,6 mU/l, and her latest KG value on IVGTT was -3.5. Baseline
HbA1c was 11.2%, dropped to 4.8% by 3 months and has remained below 6.0% since then. Levels of
anti-GAD and anti-IA2 autoantibodies have remained negative or with very low titers. She had 25% class
1 PRA positivity pre-transplant, and retrospective Luminex testing identified numerous anti-class 1 and 2
antibodies, including 2 class 1 specificities borne by her islet donors. These antibodies have been cleared
on a recent Luminex testing. MLR showed decreased reactivity against donor cells as compared to third
party.
Conclusion: This is to our knowledge the first patient to ever reach the symbolic target of 10 years insulin
independence after allogeneic islet transplantation, with remarkably normal metabolic control. Explanations for this so far uncommon finding may include low pre-transplant insulin requirements and decreased donor-specific immune responsiveness.
P 79
Inhibition der Rho-Kinase verringert CXC-Chemokin-Bildung, Leukozytenrekrutierung und hepatozellulären Schaden bei extrahepatischer Cholestase
S. Dold1, M.W. Laschke1, M.D. Menger1, S. Richter1, M.K. Schilling1, H. Thorlacius2 (1Homburg-Saar/DE,
2
Malmö/SE)
Objective: Extrahepatische Cholestase führt durch Akkumulation hydrophober Gallensäuren im Lebergewebe zu sinusoidalem Perfusionsversagen und hepatozellulärem Gewebeuntergang. Frühere Untersuchungen haben gezeigt, dass inflammatorische Prozesse wie Kupfferzellaktivierung und nachfolgende
Leukozytenrekrutierung eine Schlüsselrolle bei der Entstehung des Leberschadens spielen. Die Mechanismen der inflammatorischen Reaktion bei obstruktiver Cholestase sind jedoch bis heute nicht vollständig verstanden. Ziel der vorliegenden Studie war es zu klären, welchen Einfluss der Rho-Kinase-Inhibitor
Y-27632 auf hepatische CXC-Chemokin-Produktion, Leukozytenrekrutierung und Leberzellschädigung
unter cholestatischen Bedingungen hat.
Methods: C57BL/6 Mäuse wurden einer Ligatur des Ductus hepaticus communis (BDL) unterzogen und
somit eine obstruktive Cholestase induziert. Vor Ligatur erfolgte entweder die Applikation des Rho-KinaseInhibitors Y-27632 (10 mg/kg) oder des gleichen Volumens Trägersubstanz (PBS). Tiere ohne Gallengangsligatur dienten als Kontrolle. Nach 12 Stunden wurde mittels intravitaler Fluoreszenzmikroskopie
die hepatische Leukozytenakkumulation, der Anteil apoptotischer Hepatozyten sowie die sinusoidale Perfusion erfasst. Zur Quantifizierung des hepatozellulären Schadens erfolgte zusätzlich die Bestimmung
der Alaninaminotransferase (ALT) und Aspartataminotransferase (AST). Das Ausmaß der Cholestase
wurde über die venöse Bilirubinkonzentration definiert. Desweitern erfolgte mit Hilfe der ELISA-Technik die
Messung der CXC-Chemokine MIP-2 (macrophage inflammatory protein-2) und KC (cytokine-induced
neutrophil chemoattractant) im Lebergewebe . Mittelwerte±SEM; p<0,05.
Results: Die Gallengangsligatur bewirkte einen signifikanten Anstieg der Bilirubin-konzentration
(30,0±4,6mmol/l vs. 11,5±1,5mmol/l), eine Zunahme der hepatischen Leuko-zytenadhäsion in postsinusoidalen Venolen (1267±178mm-2 vs. 162±66mm-2), eine drastische Erhöhung der Leberenzyme
ALT (55,74±11,32mkat/l vs. 0,46±0,04mkat/l) und AST (90,06±18,29mkat/l vs. 1,22±0,13mkat/l)
sowie ein deutliches sinusoidales Perfusionversagen (30,0±3,7% vs. 5,3±0,7% ). Die CXC-Chemokinkonzentrationen im Lebergewebe fanden sich massiv erhöht. Die Inhibition der Rho-Kinase führte zu einer
signifikanten Reduktion des hepatozellulären Schadens (ALT: 4,4±1,8mkat/l ; AST: 11,3±4,0mkat/l), einer
Verminderung der Leukozytenadhäsion (502±65mm-2) und einer Verringerung des sinusoidalen Perfusionsversagens (11,2±0,8%). Applikation von Y-27632 bewirkte weiter eine verringerte Freisetzung der
CXC-Chemokine MIP-2 und KC und eine reduzierte Apotoserate (8,3±0,4% vs. 3,5±0,2%). Das Ausmaß
der Cholestase zeigte keinen Unterschied in beiden BDL-Gruppen.
Conclusion: Die vorliegende Studie zeigt, dass die Rho-kinase eine zentrale Rolle in der Pathophysiologie
der Leberdysfunktion im Rahmen der obstruktiven Cholestase einnimmt. Tatsächlich bewirkt die Inhibition
der Rho-Kinase eine Reduktion der CXC-Freisetzung, der hepatischen Leukozytenrekrutierung und des
hepatozellulären Schadens. Somit könnte eine medikamentöse Blockade der Rho-Kinase-Aktivität bei
Patienten mit extrahepatischer Cholestase eine Verbesserung der Leberfunktion bewirken.
P 97
Laparoscopic approach of idiopathic segmental infarction of the greater omentum
E. Pezzetta, M. Maternini, O. Martinet (Montreux)
Objective: Idiopathic segmental infarction of the greater omentum should be included in the the differential diagnosis in patients presenting with right sided abdominal pain, mimicking thus acute cholecystitis or
appendicitis. Laparoscopy may have a diagnostic or therapeutic role in this respect.
Methods: A case presentation of idiopathic segmental infarction of the greater omentum is reported in
order to illustrate the interest of laparoscopy in this uncommon situation
Results: A 40-years old women was admitted with abdominal pain in right flank and an abdominal CT
scan showing characteristic features of omental infarction, consisting of a heterogeneous density fatty
mass, containing hyperattenuating streaks, located in the greater omentum, between the anterior abdominal wall and the colon. Giving persisting symptoms the patient was submitted to a laparoscopy with
resection of the necrotic portion of the omentum. Pathology confirmed the diagnosis.The patient was
discharged on the 3rd postoperative day with an uneventful recovery.
Conclusion: Laparoscopy should be considered in the management of idiopathic segmental infarction of
the greater omentum. The procedure may be indicated in order to establish and confirm the diagnosis or
in case of worsening conditions of the patient despite conservative treatment.
P 98
Adult-Onset Still’s Disease (AOSD) – a rare osteoarthritis entity for the orthopedic surgeon
D. Hauke, F. Saxer, A. Tzankov, V. Valderrabano (Basel)
Objective: AOSD is an inflammatory disorder characterized by spiking temperatures, arthralgia and a
characteristic transient salmon-coloured rash. The etiology is unknown and there is only little information
on the epidemiology. The incidence was estimated at 0.16 per 100000 without a gender predilection.
There are two peaks between 15 to 25 and 36 to 46 years, only rarely patients older than 70 years. The
diagnosis is reached when certain cardinal and secondary criteria can be met (Table 1). Furthermore,
other causes have to be excluded. Apart from these criteria, serum ferritin is a relevant diagnostic marker,
which can be also used as parameter for therapeutic efficacy. NSAID`s, glucocorticosteroids and immunosuppressants are typically used depending on the disease course and clinical picture. Chronic illness
can cause joint destruction and secondary amyloidosis, life threatening complications are rare.
Methods: Case report
Results: A 59-year old woman presented with fever and clinical signs of omarthritis. Right shoulder with
painful restricted ROM, no signs of imflammation. Laboratory results with high inflammation markers and
abnormal liver function tests (Tab. 2), normal x-ray (Fig. 1). After an aspiration of the shoulder (yellow cloudy fluid, microbiologic testing with sterile leucocytosis), we performed a shoulder arthroscopy. Normal
intraarticular findings, subacromially there was a mild discharge of pus and moderate vascular injection.
We performed a subacromial debridement, a synovial biopsy (Fig. 2) and subacromial samples revealed
acute synovialitis in the histological examination, the microbiologal examinations were unremarkable. In
view of persistent pain and static levels of inflammation markers, we performed a second look arthroscopy to perform a throughout lavage for reducing a potential septic arthritis and wash out cartilage damaging enzymes. Biopsy again showed an acute synovialitis, while the bacteriologic analysis was again
sterile. After excluding malignancies, infection and other rheumatoid disease our tentative diagnosis was
an AOSD. This assumption was supported by a serum ferritin of 795 ng/ ml. Oral prednison therapy with
40 mg/ d improved the clinical picture and the inflammation markers. Discharge in a good general condition. A final check three months later showed a symptom free patient and normal laboratory findings. We
therefore assumed a favorable course with full remission.
Conclusion: This case shows that a predominantly medical condition can be most relevant for the orthopedic surgeon and illustrates that the interdisciplinar approach is very important in the osteoarthritis
diagnostic process. In the process of finding the empirically right diagnosis in this case, we excluded
75
infections, rheumatologic disorders, solid and hematological malignancies step by step. Regarding to
Tab. 1 we met 6 listed criterias (3 primary, 3 secondary ones). With hindsight a second arthroscopy might
have been avoided if we had thought of an AOSD earlier. The clinical presentation, as well as the pattern
of laboratory findings, was at the end very typical for AOSD, although the patient lacked the characteristic
rash, which might have given us a precious hint earlier. The final clue was given by the high serum ferritin
and the therapeutic success of glucocorticosteroids, which led to full remission. To our best knowledge
up to now no recurrences have been reported after initial success.
P 102
Mario Donati und die vertikale Matratzennaht der Haut: Biographisches und Anekdotisches
U. Dietz, I. Kuhfuss, A. Thiede (Würzburg/DE)
P 99
Diagnose eines Merkelzellkarzinoms – was nun?
A. Lechleiter1, R. Cecini2, U. Laffer2 (1Bern, 2Biel)
Objective: Das erstmals 1972 beschriebene Merkelzellkarzinom oder „kutane neuroendokrine Karzinom“
stellt eine seltene Tumorentität mit steigender Inzidenz dar. Risikofaktoren sind hohes Alter, Hellhäutigkeit
oder Immunsuppression. Es wird angenommen, dass das Karzinom aus der Merkelzelle der Haut hervorgeht. Die meist soliden, kugeligen Tumore sind v.a. im Bereich lichtexponierter Areale lokalisiert. Sie liegen
dermal, teilweise mit Ausdehnung bis ins subkutane Fettgewebe oder in die Muskulatur. Histologisch gehören sie zu den klein- und rundzelligen Tumoren. Die Diagnose muss immunhistochemisch gesichert
werden, wobei das Karzinom sowohl epitheliale wie auch neuroendokrine Marker exprimiert.
Methods: Wir berichten über eine 81-jährige Patientin, welche 1/2007 erstmals eine nicht schmerzhafte
Geschwulst unterhalb der rechten Leiste bemerkte. Es erfolgte eine Punktion, wobei zytologisch nur
Blutzellen nachgewiesen werden konnten. Bei Grössenprogredienz wurde 4/2007 eine CT und Biopsie
durchgeführt. Es fand sich eine 6x4,5 cm grosse, scharf begrenzte Raumforderung im subkutanen Fettgewebe; kein Hinweis auf lokoregionäre Lymphknoten- oder Fernmetastasen. Histologisch zeigte sich
ein Merkelzellkarzinom mit ausgedehnten Nekroseherden. Zuweisung der Patientin zur Resektion. Der
abgekapselte Tumor wurde in toto entfernt. 2 benachbarte, indurierte Lymphknoten wurden mitentfernt.
Die histologische Aufarbeitung bestätigte die Diagnose eines Merkelzellkarzinoms, welches R0 reseziert
wurde. Die Lymphknoten waren tumorfrei. Anschliessend wurde eine Radiotherapie mit 60 Gy durchgeführt. Bei der letzten Nachkontrolle war die Patientin beschwerde- und rezidivfrei.
Results: Die Prognose des typischerweise schnell wachsenden und früh metastasierenden Merkelzellkarzinoms ist mit einer 2-JÜR von 30-50% schlecht. Häufig sind im Verlauf Lokalrezidive und lokoregionäre
Lymphknotenmetastasen (bis zu 44 resp. 36%). Zudem treten in bis zu 50% Fernmetastasen auf. Die
Basistherapie stellt die chirurgische Resektion dar, wobei in der Literatur ein Sicherheitsabstand von 25 cm empfohlen wird. Kontrovers diskutiert wird eine primäre Lymphadenektomie. Sinnvoll scheint eine
SLN-Biopsie zu sein. Durch eine adjuvante Radiotherapie kann sowohl die Lokalrezidivrate gesenkt als
auch das Gesamtüberleben verlängert werden. Eine Chemotherapie hat aktuell lediglich bei einer Fernmetastasierung einen Stellenwert; bis anhin konnten jedoch nur kurze Remissionszeiten erreicht werden.
Bezüglich der Nachsorge gibt es keine wissenschaftlich gesicherten Daten. Meistens wird eine initial vierteljährliche Nachsorge empfohlen.
Conclusion: Das Merkelzellkarzinom ist eine seltene, rasch progrediente Tumorerkrankung des älteren
Menschen mit schlechter Prognose. Lokalrezidive, lokoregionäre Lymphknoten- und Fernmetastasen sind
häufig. Therapie der Wahl ist die radikale chirurgische Resektion mit einer adjuvanten Radiotherapie.
P 100
De Garengeot Hernia
M. Seifert (Rapperswil)
Objective: Many surgeons are familiar with Amyand hernia, which is an inguinal hernia sac containing
an appendix. The first surgeon who described an appendix in a femoral hernia sac was Rene Jacques
Croissant de Garengeot, a Parisian surgeon of the 18 th century. A case is presented and the literature is
also listed.
Methods: We present the case of an 56-year-old woman who presented with an swelling painfull femoral
hernia. The hernia was known years ago without symptoms. When opening the hernia sac we found an 5
cm long an thin appendix incarcerated with the tip. The inguinal opening was enlarged an the appendectomy made. The hernia was closed inguinal without mesh. The patient outcome was normal.
Results: Histological findings were an fresh incarceration especially of the tip of the appendix with fresh
necrosis of the fatty tissue and inflammatory reaction.
Conclusion: A very rare event is an incarcerated appendix in a femoral hernia. When the appendix is incarcerated or inflammed, appendectomy should be performed an the hernia closed with no mesh. When the
appendix is normal, appendectomy should bei avoided and the hernia can be closed with mesh.
P 101
Zum 100-jährigen Jubiläum: Franz Kuhn (1866-1929) und die Catgut-Sterilisation
U. Dietz, M. Winkler, C. Weisser, A. Thiede (Würzburg/DE)
Objective: Der lange Weg bis zur einwandfreien Catgut-Sterilisation begann mit der Arbeit Lord Listers
(1867) und endete erst 41 Jahre später. In diesem Zeitraum (1867-1906) wurden zahlreiche Sterilisationsmethoden ausprobiert und wieder verworfen, da keine der Methoden die ultimative Lösung darstellte.
Es kam immer wieder zu folgeschweren postoperativen Infektionen – insbesondere Tetanus – durch die
eigentlich „steril“ gedachten Catgut-Fäden. Auch in der Schweiz wurde diesem Problem nachgegangen.
Der Nobelpreisträger Theodor Kocher (1841-1917) aus Bern, César Roux (1884-1934) aus Lausanne,
Auguste Reverdin (1848-1908) aus Genf und Conrad Brunner (1859-1927) aus Münsterlingen haben
neben unzähligen weiteren Europäischen und Nordamerikanischen Kollegen eigene Sterilisationsmethoden beschrieben; man kann sagen, dass jeder nahmhafte Chirurg seine eigene Methode hatte. Die Catgut-Sterilisation sollte jedoch erst durch einen epistemologischen Paradigmenwechsel gelingen – vom
Axiom der Korrespondenz von Phänomenen (Analogieprinzip) zum Axiom des kausalgesetzlichen,
mechanisch-deterministischen Ablaufs von Prozessen. Ziel dieses Posters ist es, anlässlich des 100-jäh-
76
rigen Jubiläums des ersten sterilen Catguts die Entwicklung der Catgut-Sterilisationsmethode durch den
Chirurgen und Pionier der Intubationsnarkose Franz Kuhn darzustellen.
Methods: –
Results: –
Conclusion: –
Objective: Mario Donati war einer der grossen europäischen Chirurgen des Anfangs des 20. Jahrhunderts. Er absolvierte eine beeindruckende Karriere und gewann schon als junger Lehrstuhlinhaber das
Vertrauen seiner Kollegen. Sein Lebenswerk umfasst mehr als 200 Publikationen. Ziel dieses Posters ist
es auf die Entstehung der vertikalen Matratzennaht nach Donati anhand des Augenzeugenberichtes ihrer ersten Anwendung einzugehen und diese im Zusammenhang der Geschichte der Wundversorgung
darzustellen. Nach Angaben des Donati-Assistenten Antonio Biancheri sei die vertikale Matratzennaht
der Haut bereits im Mittelalter eine gängige Technik gewesen; dies konnte jedoch in den Recherchen für
die vorliegende Studie nicht sicher nachgewiesen werden. Ziel ist es auch, auf das würdige und stille
Leiden Donatis einzugehen, der als konvertierter Jude seines Amtes als Ordinarius für Chirurgie an der
Universität Mailand 1938 enthoben wurde. Er fand in der Schweiz, zunächst in Lugano bei dem Chirurgen
F. Pedotti Zuflucht. Kurz danach wechselte er als Gastprofessor an die Universität Genf, wo er Vorlesungen
als Dozent des „Fundo Europea di Soccorso agli Studenti“ hielt. Kurz nach seiner Rückkehr aus dem
Schweizer Exil, verstarb Mario Donati 1946 in Mailand. Die vertikale Matratzennaht nach Donati ist nach
wie vor, sowohl in der allgemeinen wie auch in der plastischen Chirurgie, sehr verbreitet und in unserem
Sprachraum in der Modifikation nach dem am 26. Oktober 2007 verstorbenen grossen Chirurgen Martin
Allgöwer (1917-2007) aus Basel sehr beliebt. Dass diese Naht in Nordamerika bereits 1909 von Robert
McMillen aus Wheeling, West Virginia, in einer lokalen Zeitschrift beschrieben worden war bestätigt einmal mehr, dass gewisse Fortschritte zu gegebenr Zeit einfach „reif“ sind und auch „parallel gedacht“
werden können.
Methods: –
Results: –
Conclusion: –
P 103
Peristomales pyoderma gangraenosum – nicht nur bei chronisch entzündlichen Darmerkrankungen
– ein Fallbericht
S. Lamm, M. Kocher, A. Huber (Bruderholz)
Objective: In der Literatur wird das peristomale Pyoderma gangraenosum praktisch nur bei Patienten
mit chronisch entzündlichen Darmerkrankungen beschrieben. Jedoch kann es vereinzelt auch in Abwesenheit einer CED oder eines Malignoms auftreten. Klinisch imponiert die Erkrankung in Form von
großflächigen uniloculären Ulzerationen mit Gangrän der Haut. Die Erkrankung wird nicht durch eine
Infektion verursacht und entsteht sowohl spontan, als auch nach vorhergehender Traumatisierung der
Haut. Gerade bei chirurgischen Wunden kann es deshalb schnell als postoperative Infektion fehlgedeutet
und behandelt werden. Im Gegensatz zu einer infektiösen Ursache bedarf das Pyoderma einer immunsuppressiven Therapie.
Methods: Wir möchten über den Casus einer 80 jährige Patientin mit langjährigem Descendostoma
(1994) berichten. In der ambulanten Kontrolle durch die Stomaberatung fällt eine parastomale Hautläsion (4x6 cm) auf, nässend und am ehesten durch Feuchtigkeit und Stuhl ausgelöst, bei demenzbedingter
eingeschränkter Patientencompliance. Daraufhin Hospitalisation zur Wundpflege in Absprache mit dem
chirurgischen Oberarzt. Wir vermuteten initial eine bakterielle Superinfizierung und begannen deshalb mit
einer empirischen Antibiotikatherapie. Darunter schnell progrediente Zunahme der Wundfläche (8 x 20
cm) mit dürsterroten unterminierten Rändern trotz intensiver Wundpflege.
Results: Wir möchten anhand von Bildern diesen Fall und seinen Verlauf von Beginn bis zur kompletten
Regredienz nach systemischer Therapie präsentieren. (Eine Übermittlung eines Digitalbildes war zum
Zeitpunkt der Eingabe leider nicht möglich-die „Text area Toolbar“ wurde nicht angezeigt)
Conclusion: Das Pyoderma gangraenosum ist eine seltene Erkrankung. Speziell peristomal kommt es
bevorzugt in Einheit mit CED bei visceralchirurgischen Patienten vor, aber eben nicht nur. Die Diagnosestellung ist einerseits schwierig da weder Histologie noch Laborparameter die Diagnosefindung stützen,
andererseits ist sie morphologisch auch sehr typisch. Die Erkrankung kann effektiv durch systemische
und lokale immunsuppressive Therapie behandelt werden. Eine schnelle Diagnosstellung am besten in
Absprache mit einem Dermatologen und Mut zur schnellen immunsuppresiven Therapie sind wegweisend für den Erfolg.
P 104
Torsion der Appendivermiformis – Eine seltene Differentialdiagnose rechtsseitiger Unterbauchschmerzen
S. Hoederath, C. Sträuli, D. de Lorenzi (Grabs)
Objective: Die Torsion der Appendix vermiformis ist eine sehr seltene chirurgische Entität. Seit ihrer ersten
Beschreibung 1918 sind in der Weltliteraur gerade einmal 26 Fälle beschrieben worden. Anhand dieses
Posters soll diese wenig bekannte Differentialdiagnose rechtsseitiger Unterbauchschmerzen in das Bewusstsein der chirurgischen Kollegen/-innen gerückt werden.
Methods: Anhand eines Case-Reports wird ein eigener Fall einer torquierten Appendix bei einem 95jährigen männlichen Paienten beschrieben. Zusätzlich wird eine Übersicht über die zu diesem Thema
vorhandene Literatur dargestellt.
Results: Präoperativ lässt sich eine Stiel-gedrehte Appendix klinisch meist nicht eindeutig von einer akuten
Appendizitis unterscheiden. Daher wird die Diagnose, wie auch in unserem Fall, in der Regel intraoperativ
gestellt. Die Anamnese unterscheidet sich dennoch teilweise von der der Appendizitis durch perakuten
Schmerzbeginn. Klinische Entzündungszeichen und Laborveränderungen finden sich erst später als bei
der Appendizitis, da sie, bei fehlender Entzündung, unter Umständen erst nach Einsetzen der Nekrose
und Perforation zu ewarten sind. Allerdings werden auch rezidivierende subtotale Torsionen als Ursache
für rekurrierende rechtsseitige Unterbauchschmerzen diskutiert. In Zsammenhang mit einer torquierten
Appendix sieht man laut Literatur häufiger eine auffällig lange Appendix mit pelviner Positionierung. Eine
gehäufte Erwähnung findet man in kinderchirurgischer Literatur. Die Rotation scheint häufiger gegen den
Uhrzeigersinn zu geschehen und sich im Bereich von der Basis bis 1 cm distal davon abuspielen. Eindeutige Ursachen wurden bisher nicht beschrieben. In der Literatur werden sowohl primäre, entwicklungsphysiologische, wie sekundäre Ursachen (Appendizitis, Mukozele, Lipom, Appendikolith, etc.) diskutiert.
Die Therapie ist, bei natürlich durch Nekrose drohender Perforation, in allen Fällen die Appendektomie.
Conclusion: Die Torsion der Appendix vermiformis ist eine seltene Ursache von rechtsseitigen Unterbauchschmerzen, deren Ursachen nicht abschliessend geklärt sind. Auch wenn daraus keine Konsequenz für die Therapie entsteht, sollte der/die Chirurg/-in sie im Bewusstsein haben, insbesondere, da die
Anamnese und die klinische Präsentation des Patienten sich, vor allem im Anfangsstadium, von der der
Appendizitis unterscheiden können.
P 105
Komplikationen von Dünndarmdivertikeln – eine seltene Entität
A. Witschi, R. Cecini, U.T. Laffer (Biel)
Objective: Wir wollen die Häufigkeit, Klinik, Operation und die postoperativen Komplikationen bei Patienten
mit Komplikationen einer Dünndarmdivertikulose (inklusive Duodenaldivertikeln) und Meckel`schen Divertikeln an einer Klinik mittlerer Grösse in einem definierten Zeitraum (in unserem Fall 5 Jahre) zeigen.
Methods: Wir haben unser Patientengut der letzten fünf Jahre (2002 bis 2007) mit Hilfe einer ICD-10
Recherche zusammengestellt und ausgewertet.
Results: Im gesamten Krankengut der Dünndarmdivertikel-Patienten fanden sich lediglich 6 Patienten mit
Komplikationen einer Dünndarmdivertikulose. Darunter waren zwei Patientinnen (73 und 85-jährig) mit
Komplikationen eines Duodenaldivertikels. Beide wurden aufgrund einer Cholezysto- und Choledocholithiasis, eine Patientin mit zusätzlicher Cholangitis, hospitalisiert. Bei beiden fand sich ein präpapilläres
Konkrement, welches mittels ERCP nach Papillotomie entfernt werden konnte. Anschliessend erfolgte bei
beiden Patientinnen die laparoskopische Cholezystektomie. Bei der 85- jährigen Patientin musste im Verlauf bei persistierenden Beschwerden mit MR-cholangiografisch nachgewiesener persistierender präpapillärer Stenose ( vermutlich aufgrund des Divertikels) eine offene Choledochusrevision mit Anlage einer
Choledochojejunostomie durchgeführt werden. Beide Patientinnen konnten nach 9 bzw. 11 Hospitalisationstagen beschwerdefrei nach Hause entlassen werden. Zwei Patienten (86- bzw. 64-jährig) und eine Patientin (34-j) traten mit Komplikationen einer jejunalen Divertikulose ein. Davon fanden sich bei den beiden
männlichen Patienten multiple, bei der einen Patientin ein solitäres Divertikel im Jejunum. Zwei Patienten
traten mit einer freien und der 86- jährige Patient mit einer gedeckten Perforation und Schlingenabszess
ein. Alle wurden notfallmässig operiert. Bei allen 3 Patienten erfolgte eine Dünndarmsegmentresektion.
Die Hospitalisationsdauer betrug für die junge Patientin 4 und für die beiden älteren Patienten 9 bzw.
15 Tage. Postoperative Komplikationen traten keine auf. Ein einziger Patient (45-j) präsentierte sich mit
einer Divertikulitis eines Meckel`schen Divertikels. Initial wurde der Patient mit V.a. Appendizitis operiert.
Intraoperativ fand sich eine Entzündung eines Meckel`schen Divertikels. Es wurde eine Dünndarmsegmentresektion und eine Appendektomie durchgeführt. Der Patient war 4 Tage hospitalisiert. Postoperative
Komplikationen traten ebenfalls keine auf. Bei 27 weiteren Patienten war das Meckel`sche Divertikel ein
intraoperativer Zufallsbefund.
Conclusion: Dünndarmdivertikel sind häufig aber bleiben meistens asymptomatisch. Sie sind für den
Chirurgen nur beim Auftreten der seltenen Komplikationen von Relevanz oder finden sich meist als intraoperativer Zufallsbefund.
P 106
Operative Stabilisation instabiler pertrochantaerer Femurfrakturen mit dem PFNA – 3 Fälle von postoperativer Migration der Klinge in das Hüftgelenk
A. Brunner, R. Babst (Luzern)
Objective: Pertrochantaere Femurfrakturen sind haeufig und mit zunehmender Lebenserwartung in den
Industrielaendern wird ihre Inzidenz in den kommenden Jahren ansteigen. Die osteosynthetische Versorgung dieser Frakturen stellt insbesondere bei reduzierter Knochenqualitaet besondere Ansprueche an
das zu verwendende Osteosynthesematerial. Der PFNA (Synthes) ist ein Vertreter einer neuen Generation
von intramedullaeren Implantaten, welche speziell fuer diese Indikation entwickelt wurden. Praesentiert
wird eine Zusammenstellung von Faellen einer bis dato nicht berichteten Komplikation des PFNA.
Methods: Berichtet werden 3 Faelle von instabilen, osteoporotischen AO: 31- A2 Frakturen, bei denen es
nach operativer Stabilisierung mittels PFNA im Rahmen der postoperativen Mobilisation zu einer axialen
medialen Migration der helikalen Klingen in das Hueftgelenk kam. Radiologisch fand sich kein Hinweis
auf eine Rotation des Schenkelhalses, eine Varus-Dislokation oder einen sonstigen Repositionsverlust.
Results: In 2 Faellen wurde die Klinge nachfolgend gewechselt, in einem Fall war ein totaler Hueftgelenksersatz notwendig. In allen Faellen fand sich ein intakter Gleitmechanismus.
Conclusion: Das neuartige Klingendesign zeigte in biomechanischen Studien eine verbesserte Rotationsstabilitaet sowie eine hoehere Stabilitaet bezueglich Varus-Dislokation verglichen mit dem Schraubendesign des herkoemmlichen PFN. Vorallem in osteoporotischem Knochen soll durch Verdichtung der
Spongiosa eine hoehere Stabilitaet erreicht werden. Trotzdem scheint der Widerstand gegen eine mediale
Migration nicht immer zu genuegen. Bei Patienten mit erheblicher Osteoporose vermeiden wir deshalb
das Aufbohren fuer die Helixklinge weiter als 1,5 -2 cm subchondral.
P 107
A rare cause of iliac vein blood flow obstruction: iliac schwannomas
P. Bucher, J. Sierra, S. Ostermann, Ph. Morel (Genève)
Objective: Schwannomas are infrequent neurogenic tumors which may present all along neuronal tracts.
Retroperitoneal schwannomas are generally discovered incidentally. We here present a case of iliac
schwannoma presenting with common right iliac vein compression associated with lumbar and sacral
discomfort.
Methods: Reports of a rare case of iliac schwannoma associated with right iliac vein compression treated
surgically in our department. Iconography, differential diagnosis and surgical treatment will be reviewed.
Results: Among the differential diagnosis of para-vascular iliac mass adenopathy represent the most frequent cause, however lymphatic and neurogenic tumors or mesenchymal tumors should be looked for.
We here present a rare case of neurogenic tumor, schwannoma, which was treated by complete surgical
resection through a right iliac fossa incision and extraperitoneal approach. After resection right iliac vein
blood flow recovered immediately and obstruction had to be attributed to mechanical compression.
Conclusion: Complete surgical resection is the gold standard of retroperitoneal schwannoma treatment.
As these tumors are generally well encapsulated surgical complete surgical resection is in the majority of
cases affordable. Attention should be paid to avoid neurologic complications as these tumors are in the
rule close to neurologic structure.
P 108
Life before limb? – Even in case of a bilateral transfemoral traumatic amputation in a 79-year old
patient?
C. Fuchs, C. Hueber, M. Di Lazzaro (Aarau)
Objective: Trauma is the second leading cause of amputation in the United States. We report a special
case of a bilateral transfemoral traumatic amputation in a 79-vear old patient.
Methods: Case: A 79-year old male biker being run over by a semitrailer crushed both legs at different anatomic levels. The left foot lay under a wheel. After rescuing the patient was stable and awake. 15 minutes
after reaching the emergency room he became unstable and needed intubation. Both legs were extremely mangled. The right leg showed massive soft tissue damage from hip to toe with an unreconstructable
lesion of the femoral artery. The left lower leg was white and pulsless with open fractures at several levels.
The total Mangled Extremity Severity Score was 11. We immediately performed a transfemoral amputation
on the right and a below-knee amputation on the left. Amputation level depended on soft tissue damage.
Revision amputations to a higher lever and several debridements followed due to stump necrosis and
persistent wound infection and finally ended in a proximal transfemoral amputation on the right and a
distal transfemoral amputation on the left. We didn‘t intend to create stumps fitting for prosthesis. The
patient required intensive post-operative management for sepsis with pseudomonas aeruginosa, including broad-spectrum antibiotics. 22 days after admission the patient was discharged from the intensive
care unit. After frequent dressing changes and treatment with wound VAC extensive skin grafting was
performed for closure of the large skin defect, especially on the right stump. 2 months after admission
the patient was discharged to rehabilitation facility. He finally was able to perform the transfer out of the
wheel-chair and was satisfied with the quality of life.
Results: In this case the amputation safed our patient‘s life - and according to him this life is satisfactory.
Conclusion: The goal of treating traumatic amputations is initially to save the person’s life, and then to
restore as much function as possible. This may be also true for bilateral above-knee amputation in elderly patients, even though the rehabilitation potential is very limited. Although a return to active social
life is probably impossible for the majority of geriatric lower limb amputees, most of them are still able to
ambulate at home.
P 109
Delayed fasciotomy in Volkmann’s contracture and a different way to secondary wound closure
A. Nagy, P.R. Meschberger, R. Fricker, A. Huber (Bruderholz)
Objective: The compartment syndrome is an injury of tissue or organs caused by increased pressure within a confined space following trauma or surgery. It results in impaired blood supply, muscle destruction
and nerve damage. Principally every anatomical compartment can be affected but it is mainly found on
forearms and lower legs, seldom intraabdominal. Leading signs are massive pain and hypoesthesia.
Later loss of muscular function and decreased blood circulation can occur. Treatment is urgent and needs
decompression of the compartment by fasciotomy. Missed diagnose or delayed therapy can cause permanent and irreversible damage in nerves and muscles as they can get necrotic. The consequence can
be paralysis or loss of the affected extremity. On the forearm these findings are known as Volkmann’s
contracture, hand and wrist are in a permanent flexion resulting in a claw-like deformity of the hand and
the fingers.
Methods: Case report. On a business trip to shanghai a 53-year old man crouched a whole night unconscious in his hotel room with his arms and hands folded on his knees after a business dinner and
consumption of indigenous hard liquor. The next morning he woke up with a swollen left arm and
blisters all over both hands. The following 6 days he has been treated in a local hospital with steroids
and vitamins. After returning to Switzerland he presented to our hospital with a left swollen forearm and
signs of ulnar nerve lesion including a claw hand and loss of sensibility in all fingers. Active flexion and
extension was impossible. Blood circulation was preserved. According to our diagnose of compartment syndrome with Volkmann’s contracture we performed immediate fasciotomy of the forearm and
decompression of Guyons canal. The initial treatment after the fasciotomy included V.A.C.® Therapy
followed by a secondary suture in shoe lace-technique which allowed continuous adaptation of the
wound without any further operation and anesthesia. For the shoe lace-technique we took vessel loops
which were fixed on clips. According to the decrease of the swelling the loops could be pulled tight daily
until the wound was closed completely. Then the secondary suture was performed.
Results: During hospitalization sensibility and muscular strength improved. After intensive ergotherapeu-
77
tic care and different braces the patients muscular strength is back to almost normal, an extension deficit
of 10 (Dig IV) and 30 (Dig V) degrees is persisting in the proximal interphalangeal joint. Thumb-Opposition is completely possible. 2-point discrimination is in all fingers at 4 mm. The elektromyography is
yet to be performed. What we already can see is a significant subjective improvement in sensibility and
muscular strength.
Conclusion: Strong suspicion of a compartment syndrome needs quick fasciotomy. Already 6 hours are
enough to cause irreversible damages. In our case 9 days passed between trauma and operation. Even
after that time it is possible to limit the damage and improve the sensibility and muscular strength through
fasciotomy.
the muscular function, a very good outcome could be achieved.
Conclusion: The compartment syndrome of the tigh is a rare condition. It is usually associated with femoral fractures or heavy blunt trauma. In our case the acute compartment syndrome of the tigh was
caused by extreme rhabdomyolysis after a marathon race. In the literature only a few case reports about
this condition can be found.
P 110
Objective: Mallet injuries are avulsions of the terminal extensor tendon, with or without a bony fragment,
resulting in a characteristic axial loading or a forceful flexion of the extended digit. Clinically there is a
sudden loss of extension of the distal interphalangeal (DIP) joint. In nonsurgical treatment by immobilisation, complications as joint stiffness, skin maceration, loss of extension and hyperextension deformity
have been reported. On the other hand most of the surgical techniques have the disadvantage of open
incisions. The inclusion criteria for surgery by the extension block technique are a closed, displaced mallet
fracture involving radiologically 25% or more of the articular surface or a fracture associated with DIP
joint subluxation.
Methods: The extension block fixation technique was first described by Ishiguro et al. in 1988. After the digit is anesthetized via a digital block, DIP joint is maximally flexed. Using fluoroscopic imaging, a Kirschner
wire is inserted percutaneously through the extensor tendon in the distal portion of the middle phalanx.
The wire provides an extension block for the bony fragment when the DIP joint is extended to reduce
the fracture. After obtaining an anatomic reduction, the distal interphalangeal joint is immobilized with a
second wire placed longitudinally across the joint to maintain the extension and reduction. A removable
postoperative extension splint was placed to protect the pins and to block DIP motion for 2-6 weeks. Both
wires are removed after 4-6 weeks, once there is radiological evidence of healing. A total of 7 patients with
8 mallet fractures of the distal phalanx were retrospectively reviewed to determine the results of treatment,
range of motion and associated complications.
Results: There were 6 men and 1 woman, with an average age of 35 years (range, 18-47 years) treated
between February 2007 and January 2008, all ambulant. The average fracture size was 40% of the joint.
The right hand was involved in 4 cases, the left in 3. In 4 cases the initial injury was sustained during
sporting. The K-wires were removed after 4-6 weeks. In one patient the wires were removed early due
to an infection. We obtained in the vast majority excellent results concerning the range of motion and
functionality of the digit. A Sudeck’s Syndrome occurred in one case. There were no nonunions, malunions
or osteomyelitis.
Conclusion: The technique is easy to perform and an effective method of treatment for displaced mallet
finger fractures with satisfactory results. It is minimally invasive and it allows an early mobilisation making
it very suitable for the patients. The duration of operation is very short as well as the radiation exposure.
Fit at all costs: bilateral exertional compartment syndrome
O. Gié, M. Bernasconi, P. Biegger (Locarno)
Objective: 19-year-old woman in good general conditions came after intensive exercise and use of anabolic steroids at our emergency room with a bilateral anterior compartment syndrome.
Methods: On physical examination we found a patient without fever and with a normal circulation. Her
shins appeared to be red, warm, tender and with a pitting edema, particularly in the anterior loge. Besides
she was noted to have paresthesia in the region of the deep peroneal nerve and a weakness of the ankleand big toe dorsiflexion
Results: Blood analyses showed a rhabdomyolyse without signs of acute renal failure. During the operation we found grey-coloured necrotic muscular tissue with edema. In the follow-up the patient showed a
residual bilateral footdrop with a persistent weakness in the ankle and big toe dorsiflexion.
Conclusion: Acute exertional (atraumatic) bilateral compartment syndrome is a very rare, but handicapping complication of the abuse of anabolic steroids. In the literature we couldn’t find other similar presentations. As a co-etiology we also think at the intensive exercise. The surgical fasciotomy is an emergency
procedure, that can lead to a better outcome with less residual complications. Last but not least we could
discuss about the development of the abuse of anabolic steroids thanks to the web market and the increased possibilities to find out those damaging substances.
P 111
Reduktion der Hospitalisationsdauer durch Abgabe von immunmodulierender Ergänzungsnahrung
durch das Spital
B.M. Galliker, V. Schreiber, J.A. Wydler, R. Schlumpf (Aarau)
Objective: Präoperativ eingenommene immunmodulierende Ergänzungsnahrung mit Zusätzen wie omega-3-Fettsäuren, RNA und Arginin bewirkt durch Minimierung der Infekte und Komplikationen eine Reduktion an Hospitalisationstagen. Von dieser Ergängzungsnahrung profitieren Mangelernährte, wohlernährte
mit gastro-intestinalem Tumor sowie Patienten vor grossem elektivem viszeralchirurgischem Eingriff. Seit
August 2006 wird Oral Impact® (OI) unseren Patienten vor grossem viszeralchirurgischem Eingriff gratis
abgegeben. Das Ziel ist die Infektrate zu reduzieren und die Hospitalisationsdauer zu verkürzen.
Methods: Das Spital übernimmt die Einkaufskosten von OI, welches nicht auf der Spezialitätenliste ist und
deshalb nicht von den Krankenkassen übernommen wird. OI wird seit August 2006 den Patienten vor
elektiven Kolon-, Magen-, Oesophagus- und Pankreasoperationen, sowie Mangelernährten direkt in der
Sprechstunde mit der schriftlichen Erklärung der genauen Einnahme abgegeben. Bis Ende November
2007 bekamen 135 Patienten OI, welche dies während den letzten 5 präoperativen Tagen dreimal täglich
einnehmen sollten. Beurteilt werden die Hospitalisationstage, die Komplikationsrate sowie die Kosten der
nach Mipp (Modell für integrierte Patientenpfade: Behandlungsabhängige Pauschale zwischen dem Spital und den Krankenkassen) abgerechneten Patienten, im Vergleich mit den Zahlen aus dem Jahr 2005.
Die Erfassung der Komplikationen erfolgt nach AQC.
Results: Erste Daten liegen von den Kolon-, Magen-, Oesophagus- und Pankreasoperationen vor. Bei den
Kolonoperationen bekamen 63 Patienten OI, die elektiv operiert und nach Mipp abgerechnet wurden. Die
durchschnittliche Hospitalisationsdauer betrug 13,9 Tage. Dies entspricht im Vergleich zum Jahr 2005
einer Reduktion um 3,3 Tage (118 Patienten, Hospitalisationsdauer 17,2 Tage). Vom Kollektiv der Oesophagusoperationen erhielten 8 Patienten OI und waren im Durchschnitt drei Wochen hospitalisiert. Damit
konnte im Vergleich zu den 6 Patienten im Jahr 2005 eine Reduktion um eine Woche erreicht werden. Bei
den Pankreasoperationen konnte die Hospitalisationsdauer durchschnittlich um 1,8 Tage verkürzt werden (6, respektive 14 Patienten). Bei den Magenoperationen betrug die Hospitalisationsdauer 21,5 Tage.
Dies entspricht einer Zunahme um 6 Tage (9 versus 13 Patienten).
Conclusion: Durch Abgabe von immunmodulierender Ergängzungsnahrung konnten wir die Hospitalisationsdauer insgesamt reduzieren. Die Reduktion um 3,3 Tage bei den Kolonoperationen ist mit der
Literatur vergleichbar. Die geringe Zahl der Magen-, Oesophagus- und Pankreaspatienten, die in dieses
Protokoll eingeschleust werden konnten, erlaubt in diesem Gebiet keine korrekte Aussage. Bei diesen Operationen ist aber auch eine Tendenz zur Reduktion der Hospitalisationszeit erkennbar.
P 112
Bilateral compartment syndrome of the tighs due to rhabdomyolysis after extreme exercise: a case
report
P. Saudan, A. Zehnder, A. Biraima, A. Haller, K. Käch (Winterthur)
Objective: We want to report about a patient who developped an extreme rhabdomyolysis after taking
part on a marathon race. This led to multiple organ failure with respiratory and renal insufficiency, compromised hemostasis and a bilateral compartment syndome of the tighs.
Methods: With this case report we want to show the needed treatment, the surgical approach, the clinical
and laboratory findings and the history of the case.
Results: In spite of the multi organ failure, the patient didn‘t suffer from any late sequelae after prolonged
intensive care with intubation, continuous hemodialysis and several surgical procedures . Even regarding
78
P 113
An almost forgotten technique for the treatment of Mallet finger fracture
J.D. Widmer, A. Missbach-Kroll, T. Sanchez, L. Meier (Olten)
Index
A
G
Acklin Yves, Dr., Kantonsspital Graubünden, 7000 Chur
15.8, 16.1,53.5
Adamina Michel, Dr., Universitätsspital Basel, 4031 Basel
Galli Raffaele, Dr., Ospedale Regionale di Lugano, 6900 Lugano
16.10
3.9. 19.3
Galliker Beat Martin, Dr., Kantonsspital Aarau, 5001 Aarau
55.15, P111
Altgeld Katrin, Dr., Kantonsspital St.Gallen, 9007 St.Gallen
17.9
Gambazzi Franco, Dr., Universitätsspital Basel, 4031 Basel
15.6, 15.7
Andres Axel, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
55.1
Gehrer Simone, St.Claraspital Basel, 4016 Basel
Azagury Dan, Dr., Hôpital Neuchâtelois Pourtalès, 2000 Neuchâtel
17.8, 55.13
Azizi Sébastien, Dr., Kantonsspital Aarau, 5001 Aarau
16.11
6.8
Gelpke Hans, Dr., Kantonsspital Winterthur, 8401 Winterthur
55.1, P22
Gervaz Pascal, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
Gié Olivier, Ospedale Regionale di Locarno La Carità, 6600 Locarno
B
7.2
7.17, P110
Giuliani Mauro, Dr., Kantonsspital Aarau, 5001 Aarau
P31
Bach Christian, Dr., Kantonsspital Aarau, 5001 Aarau
P44
Grafen Franziska C., Dr., Spital Limmattal, 8952 Schlieren
35.4
Baertschiger Reto Marc, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
43.8
Grieder Felix, Dr., Kantonsspital Winterthur, 8401 Winterthur
55.4
Grillet Marie-Pierre, Dr., Kantonsspital Graubünden, 7000 Chur
15.5
Grosskreutz Anja, Spital Frutigen, 3714 Frutigen
17.6
Bänninger Philpp, Stadtspital Triemli, 8063 Zürich
5.3
Banz Vanessa, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
3.3, 52.3, 52.6
Bauknecht Felix, Dr., GZO Spital Wetzikon, 8620 Wetzikon
54.9
Beldi Guido, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
43.4
H
Bergner Michael, Dr., Spital Thun-Simmental, 3600 Thun
51.5
Habelt Susanne, Dr., Kinderspital Basel, 4005 Basel
Bestetti Valentina, Dr., Spital Thun-Simmental, 3600 Thun
16.7
Hagen Monika, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
Bischofberger Stephan Andreas, Dr., Kantonsspital St.Gallen, 9007 St.Gallen
16.2
Hahnloser Dieter, PD Dr., Universitätsspital Zürich, 8091 Zürich
35.3
Halkic Nermin, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
21.5
P73
Bodmer Elvira, Stadtspital Triemli, 8063 Zürich
5.6
P47
6.1, 31.5, 35.2
Bommeli Sandra, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
16.6
Hasenböhler Erik A., Dr., University of Colorado School of Medicine, US-80204 Denver
Borbély Yves, Inselspital, Universitätsspital Bern, 3010 Bern
55.2
Hasler Rebecca, Inselspital, Universitätsspital Bern, 3010 Bern
8.9
Hauke Dorin, Universitätsspital Basel, 4031 Basel
P98
Breitenstein Stefan, Dr., Universitätsspital Zürich, 8091 Zürich
52.1, 52.2, 52.9
Brunner Alexander, Kantonsspital Luzern, 6000 Luzern
Bucher Pascal, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
53.8, P106
35.1, 35.5, 55.5. 55.9, P19, P42, P107
Buchli Christian, Dr., Kantonsspital Graubünden, 7000 Chur
Bundi Marcel, Kantonsspital Aarau, 5001 Aarau
Businger Adrian P., Dr., Universitätsspital Basel, 4031 Basel ??
31.1
Heizmann Oleg, Dr., Universitätsspital Basel, 4031 Basel
Herden Uta, Inselspital, Universitätsspital Bern, 3010 Bern
5.7, 17.2,17.4, 17.12
Candrian Christian, Dr., Kantonsspital Bruderholz, 4101 Bruderholz
6.9
Heinrich Stefan, Universitätsspital Zürich, 8091 Zürich
17.10
C
Can Ünal, Dr., Stadtspital Triemli, 8063 Zürich
Heinicke Jean-Marc Marc, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
43.3
55.7
23.2, 23.5, 25.6, P21
Hetzer Franc, Dr., Kantonsspital St.Gallen, 9007 St.Gallen
31.3
Hoederath Sascha, Dr. Kantonsspital Grabs, 9472 Grabs
P104
Honigmann Philipp, Dr., Kantonsspital Luzern, 6000 Luzern
53.1, 53.6
4.3
Horisberger Monika, Dr., Universitätsspital Basel, 4031 Basel
53.9
Huber Xaver S., Dr, Universitätsspital Basel, 4031 Basel
43.6
Carboni Giovanni Luca, Inselspital, Universitätsspital Bern, 3010 Bern
15.2
Huber Christoph, CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
44.6
Cardell Markus, Universitätsspital Zürich, 8091 Zürich
P74
Hübner Martin, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
25.2
Charbonnet Pierre, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
11.4
Hurni Michel, CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
34.5
Cheng Cai, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
7.4, 19.7
Cikirikcioglu Mustafa, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
Cresce Giovanni D., HUG Hôpitaux Universitaires de Genève, 1211 Genève
7.1
31.8, 34.1
34.7
D
de Rougemont Olivier, Dr., Universitätsspital Zürich, 8091 Zürich
23.4, 43.9
I
Imhof Adrienne, Dr., Kantonsspital Schaffhausen, 8208 Schaffhausen
P36, P43
Inan Ihsan, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
21.2, P27
Inglin Roman, Dr., Hôpital Cantonal Fribourg, 1708 Fribourg
P26
Innocente Francesco, HUG Hôpitaux Universitaires de Genève, 1211 Genève
58.4
de Stefano Eleonora, CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
34.3
Iezzi Giando, Dr. , Universitätsspital Basel, 4031 Basel
Delgadillo Xavier, Dr., Clinique Montbrillant, 2300 La Chaux-de-Fonds
31.4
Isaak Andreas, Kantonsspital Aarau, 5001 Aarau
Descombes Simon, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
34.8
Deyle Simone, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
52.4
J
Dick Florian, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
51.1
Janzen Jan, Dr., Praxis für Histopathologie, 3073 Gümligen
4.2, 17.18, P101, P102
Jeger Victor, Inselspital, Universitätsspital Bern, 3010 Bern
Dietz Ulrich, PD Dr., Universitätsklinikum Würzburg, DE-97080 Würzburg
Dindo Daniel, Dr., Universitätsspital Zürich, 8091 Zürich
11.9, 25.3, 25.4
P75
17.13
51.2
8.6
Joos Renzo, Dr., Kantonsspital Graubünden, 7000 Chur
53.3
Dold Stefan, Universitätsklinik des Saarlandes, DE-66421 Homburg/Saar
P79
Jost Rahel S., Kantonsspital Winterthur, 8401 Winterthur
Donadini Andrea, Dr., Hôpital du Jura, 2800 Delémont
P49
Jungraithmayr Wolfgang, Dr., Universitätsspital Zürich, 8091 Zürich
Dormond Olivier, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
7.12
Drescher Eva K., Hôpital Cantonal Fribourg, 1708 Fribourg
Droeser Raoul A., PD Dr., Universitätsspital Basel, 4031 Basel
P38
4.8, 44.3
P30
15.10, 43.7
K
Kaipel Martin, Dr., Universitätsspital Basel, 4031 Basel
5.1
Kalak Nabil, Dr., Kantonsspital St.Gallen, 9007 St.Gallen
E
Engelberger Stephan, Universitätsspital Basel, 4031 Basel
17.17
Kam Richard, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
4.7
Karaca Saziye, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
Karoubi Golnaz, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
F
Fahrner René, Dr., Spital Limmattal, 8952 Schlieren
55.17
16.13, 34.4
7.9, P76
Keel Marius, PD Dr., Universitätsspital Zürich, 8091 Zürich
6.7, 35.7
8.5
Kern Beatrice, Dr., St.Claraspital Basel, 4016 Basel
3.6, 3.8
Feer Rudolf, Hôpital Cantonal Fribourg, 1708 Fribourg
13.3
Kessel Kristina, Spitalzentrum Biel, 2501 Biel
17.5
Feder-Mengus Chantal, Universitätsspital Basel, 4031 Basel
P77
Kim Hyunju, Kantonsspital Aarau, 5001 Aarau
44.4
Fenner Hartwig, Kantonsspital Luzern, 6000 Luzern
53.7
Kolb Walter, Dr., Kantonsspital St.Gallen, 9007 St.Gallen
25.5
Freitas Alexis, Kantonsspital St.Gallen, 9007 St.Gallen
15.4
Kotzampassakis Nikos, CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
15.3
Krueger Thorsten, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
15.9
Frey Daniel Mathias, Dr., Universitätsspital Basel, 4031 Basel
Froment Philippe, Dr., Hôpital Cantonal Fribourg, 1708 Fribourg
Fuchs Corina, Dr., Kantonsspital Aarau, 5001 Aarau
6.3, 19.1
P39
P52, P108
Füglistaler Philipp, Dr., Universitätsklinik des Saarlandes, DE-66421 Homburg/Saar
51.3
Furrer Katarzyna, Dr., Universitätsspital Zürich, 8091 Zürich
19.9
79
L
S
Lamm Sebastian, Dr. Kantonsspital Bruderholz, 4101 Bruderholz
Langer Igor, PD Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
P103
4.6
Saucy François, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
13.4
Saudan Patrick, Kantonsspital Winterthur, 8401 Winterthur
P112
Larusson Hannes Jon, Dr., Universitätsspital Basel, 4031 Basel
21.4
Savolainen Hannu, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
Laschke Matthias W., Universitätsklinik des Saarlandes, DE-66421 Homburg/Saar
26.6
Saxer Franziska, Dr., Universitätsspital Basel, 4031 Basel
Lässker Roman, Dr., Kantonsspital Winterthur, 8401 Winterthur
Lechleiter Antje, Dr., Spitalzentrum Biel, 2501 Biel
4.4, 16.4
Schafer Miranda, Spitalzentrum Biel, 2501 Biel
13.1, 44.7, 51.6
17.7
8.7
P99
Schmidt Christian, Dr., Universitätsspital Zürich, 8091 Zürich
Lehmann Kuno, Dr., Universitätsspital Zürich, 8091 Zürich
23.1
Schnider Annelies, Dr., Stadtspital Triemli, 8063 Zürich
Linke Georg R., Dr., Kantonsspital St.Gallen, 9007 St.Gallen
35.8
Schuld Jochen, Dr., Universitätsklinik des Saarlandes, DE-66421-Homburg/Saar
Loup Ophélie, Inselspital, Universitätsspital Bern, 3010 Bern
58.7
Schulze Jens, Dr., Universitätsspital Basel, 4031 Basel
5.5
Lustenberger Thomas, Universitätsspital Zürich, 8091 Zürich
8.3
Schwarz Steffen J., Dr., Spital Lachen AG, 8853 Lachen
16.8
Lütolf Magdalena, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
58.3
M
Schwenter Frank, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
7.11
3.4, 3.5
3.1, 13.6
19.2, P41
Sconocchia Giuseppe, Dr., Universitätsspital Basel, 4031 Basel
7.10
Seifert Martin, Dr., Spitalregion Fürstenland Toggenburg, 8640 Rapperswil
P100
43.2
Majno Pietro Edoardo, PD Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
23.3
Sgroi Antonino, HUG Hôpitaux Universitaires de Genève, 1211 Genève
Marra Francesco, Kantonsspital St.Gallen, 9007 St.Gallen
11.3
Shamdasani Sonja, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
Marti Lukas, Dr., Kantonsspital St.Gallen, 9007 St.Gallen
55.8
Skala Karel, HUG Hôpitaux Universitaires de Genève, 1211 Genève
11.5
Slotta Jan E., Dr., Universitätsklinik des Saarlandes, DE-66421 Homburg/Saar
43.1
Soll Christopher, Universitätsspital Zürich, 8091 Zürich
19.4
Martinolli Luca, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
Mastrocola Mario, Dr., Spitalzentrum Biel, 2501 Biel
8.2
16.12
8.1
Maternini Matteo, Dr., Hôpital Riviera, 1820 Montreux
P50
Soyka Rahel, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
Matt Peter, Dr., Universitätsspital Basel, 4031 Basel
58.1
Stärkle Ralph Fabian, Dr., Kantonsspital Graubünden, 7000 Chur
Mayer Dieter, Dr., Universitätsspital Zürich, 8091 Zürich
44.5
Steinemann Daniel, Dr., Universitätsspital Zürich, 8091 Zürich
Meili Severin, Dr., Kantonsspital Aarau, 5001 Aarau
16.4
Steinmann Claudia, Dr., Kantonsspital Baden, 5404 Baden
P25
Meyer Philipp, Dr., Stadtspital Triemli, 8063 Zürich
3.2
Stengel Patricia, Hôpital Cantonal Fribourg, 1708 Fribourg
21.3
Mica Ladislav, Dr., Kreisspital Männedorf, 8087 Männedorf
P51
Studer Peter, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
Miot Sylvie, Dr., Universitätsspital Basel, 4031 Basel
26.2
Misirlic Merima, Stadtspital Triemli, 8063 Zürich
Missbach-Kroll Antje, Dr., Kantonsspital Olten, 4852 Olten
Morel Philippe, Prof. Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
3.7
53.2
6.5, 31.2
Moritz Wolfgang, Dr., Universitätsspital Zürich, 8091 Zürich
7.16
Muff Brigitte, Dr., Spital Bülach, 8180 Bülach
54.6
Müller Andreas, Dr., Universitätsspital Basel, 4031 Basel
Müller Daniel Andreas, Spital Frutigen, 3714 Frutigen
Müller Yannick, HUG Hôpitaux Universitaires de Genève, 1211 Genève
Müller-Stich Beat P., Universität Heidelberg, DE-69120 Heidelberg
Myers Patrick O., HUG Hôpitaux Universitaires de Genève, 1211 Genève
26.5, 53.4
43.5
55.12
10.2, 16.5, 31.7, 34.2, 34.6
Nagy Alexandra, Dr., Kantonsspital Bruderholz, 4101 Bruderholz
P109
Nett Philipp C., Dr, Inselspital, Universitätsspital Bern, 3010 Bern
7.6
Niclauss Lars, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne 35.9
25.1, 52.5
T
Thenisch Tina, Kantonsspital St.Gallen, 9007 St.Gallen
P33
Tozzi Piergiorgio, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
58.5
U
Uglioni Bettina, Dipl.Phys, St.Claraspital Basel, 4016 Basel
6.2
5.9
N
Niclauss Nadja, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
8.8
4.1, P53
7.8, 55.10, P78
V
Vandoni Riccardo E., Dr., Ospedale San Giovanni, 6500 Bellinzona
55.3
Vergnat Mathieu, CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
58.2
Vidovic Mile, Kantonsspital St.Gallen, 9007 St.Gallen
16.3
Viehl Carsten T., PD Dr., Universitätsspital Basel, 4031 Basel
11.1
von Allmen Regula, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
von Holzen Urs, Dr., Kantonsspital Olten, 4600 Olten
von Roll Andreas Louis, Dr., Universitätsspital Basel, 4031 Basel
13.5, 16.9
54.8
5.2
13.2
W
O
Wagner Oliver J., Inselspital, Universitätsspital Bern, 3010 Bern
Ochsner Alex, Dr., Universitätsspital Basel, 4031 Basel
11.2
Walpoth Beat H., Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
Oesch Antoine, Dr., Spitalzentrum Biel, 2501 Biel
P37
Weber Damian Oswald, Dr., Kantonsspital Schaffhausen, 8208 Schaffhausen
Olmi Stefano, Dr., San Gerardo Hospital, Monza, IT-20124 Milano
4.5
Weber Walter Paul, Dr., Universitätsspital Basel, 4051 Basel
7.7
Wenger Christa, Universitätsspital Zürich, 8091 Zürich
Osman Ashraf, Dr., Universitätsspital Zürich, 8091 Zürich
Oulhaci Wassila, Hôpital de Nyon, 1260 Nyon
10.1, P48
P
Perentes Jean Yannis, CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
Perez Daniel, Dr., Stadtspital Triemli, 8063 Zürich
26.4
15.1, 19.6
P35
54.1, 54.3
6.4
Widmer Jeannette Deborah, Dr., Kantonsspital Olten, 4600 Olten
P113
Widmer Matthias Kurt, PD Dr., Inselspital, Universitätsspital Bern, 3010 Bern
31.6
Wiewiorski Martin, Universitätsspital Basel, 4051 Basel
Pasch Antonie E., Dr., Kantonsspital Aarau, 5001 Aarau
4.9, 35.6
34.1, 34.7
Wilhelm Markus, PD Dr., Universitätsspital Zürich, 8091 Zürich
Wilmink Beate Michaela, Kantonsspital Bruderholz, 4101 Bruderholz
P72
58.6, 58.8
P45
17.1
Witschi André, Dr., Spitalzentrum Biel, 2501 Biel
Perruchoud Delphine, Dr., Hôpital Cantonal Fribourg, 1708 Fribourg
P34
Wolff Katja, Dr., Kantonsspital St.Gallen, 9007 St.Gallen
11.8, 52.8
Petermann David, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
52.7
Wolff Thomas, Dr., Universitätsspital Basel, 4031 Basel
7.3
Pezzetta Edgardo, Dr., Hôpital Riviera, 1820 Montreux
P32, P97
Pfefferkorn Urs, Dr., St.Claraspital Basel, 4016 Basel
54.2, 54.5
P105
Z
Pittet Olivier, Dr., CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
P40
Zeh Nina, Dr. Hôpital Cantonal Fribourg, 1708 Fribourg
P28
Platz Andreas, Prof. Dr., Stadtspital Triemli, 8063 Zürich
5.8
Zerz Andreas, Dr., Kantonsspital St.Gallen, 9007 St.Gallen
21.6
Pohle Sebastian, Kantonsspital Baden, 5404 Baden
54.7
Zimmerer Rüdiger M., Dr., Universitätsspital Basel, 4031 Basel
Potocnik Primoz, Kantonsspital Graubünden, 7000 Chur
17.16
Zingg Tobias, Dr., Hôpital Cantonal Fribourg, 1708 Fribourg
Pugin Francois, HUG Hôpitaux Universitaires de Genève, 1211 Genève
17.14
Zingg Urs, Dr., Universitätsspital Basel, 4031 Basel
Zürcher Manuel Lukas, Dr., Universitätsspital Basel, 4031 Basel
R
Raafat Nermin, Dr., Universitätsspital Basel, 4031 Basel
19.8
Reck Stefan, Dr., Universitätssspital Basel, 4031 Basel
44.2
Regusci Luca, Dr., Ospedale Beata Vergine, 6850 Mendrisio
P46
Rezaeian Farid, Dr., HUG Hôpitaux Universitaires de Genève, 1211 Genève
26.1
Ris Frédéric, HUG Hôpitaux Universitaires de Genève, 1211 Genève
Roggo Antoine, PD Dr., Inselspital, Universitätsspital Bern, 3010 Bern
7.15, 55.6
17.3
Roh Vincent, Inselspital, Universitätsspital Bern, 3010 Bern
P71
Rohrhuber Sophia, Dr., Inselspital, Universitätsspital Bern, 3010 Bern
10.3
Romy Sebastien, CHUV Centre Hospitalier Universitaire Vaudois, 1011 Lausanne
P29
Rouden Christophe, Dr., Universitätsspital Basel, 4031 Basel
51.4
80
7.13
P20, P23
11.6, 55.14, 55.16
P24
Congress Topics
Modetrend oder Methode der Wahl?
Die palmare winkelstabile Plattenosteosynthese der instabilen distalen Radiusfraktur
Mark A. Rudin, mark.rudin@ksw.ch
Kurt P. Käch, kurt.kaech@ksw.ch
Die distale Radiusfraktur verletzt das mechanische Fundament des wichtigsten menschlichen Werkzeugs. Ziel der Behandlung dieser häufigen Verletzung ist die Wiedererlangung eines schmerzfreien, unbehinderten Einsatzes
der Hand in Alltag, Beruf und Sport.
Tendenziell zeigt sich eine zweigipflige Altersverteilung: Einerseits die komplexen high-velocity Verletzungen jüngerer Patienten, andererseits die Frakturen des osteoporotischen Knochens älterer Patienten. Die erste Gruppe
zeigt eine zunehmende Risikobereitschaft. Bei der zweiten steigt bei demographisch zunehmender Gruppengrösse gleichzeitig die Sturz- und Osteoporosehäufigkeit. Beide Patientengruppen stellen hohe Ansprüche an die Versorgung. Sie erwarten gute Langzeitergebnisse und eine möglichst schnelle
Wiedererlangung der Extremitätenfunktion.
Die Versorgungsmöglichkeiten distaler Radiusfrakturen umfassen die Gipsfixation mit oder ohne Reposition, die transfragmentäre oder intrafokale Spickdrahtosteosynthese, die Retention mittels handgelenksüberbrückendem Fixateur externe sowie die Plattenosteosynthese.
Abb. 1
Bei der häufigeren, nach dorsal dislozierten Extensionsfraktur zeigt die dorsal
abstützende konventionelle Plattenosteosynthese mechanische Vorteile, biologisch jedoch Nachteile in Form von konsumierenden Zugängen und Sehnenirritationen bei dünnem dorsalem Weichteilmantel. Mit der konventionellen
volaren Platte lassen sich Frakturen mit ausgeprägter dorsaler Trümmerzone
ohne Spanplastik ungenügend retinieren.
Mit der Verwendung von winkelstabilen Plattensystemen können Extensionsfrakturen trotz ausgeprägter dorsaler Trümmerzone volarseitig stabilisiert werden. Auf eine Span- oder Spongiosaplastik kann verzichtet werden. Voraussetzung hierfür ist eine stabile, subchondrale Verblockung im distalen Fragment
(Prinzip des Fixateur interne, Abb. 1). Die klassische bikortikale Schraubenverankerung ist unnötig und sollte vermieden werden (Rupturen oder Tenosynovialitis der Extensorsehnen). Die Verblockung von Schraube und Platte
verhindert eine Schraubendislokation mit Irritation der Beugesehnen.
Der palmare Zugang nach Henry schont die dorsalen Sehnenleitsysteme. Die
meist einfach frakturierte palmare Kortikalis kann dank der guten Übersicht
anatomisch, unter Wahrung der korrekten Länge und ohne Rotationsfehler
reponiert werden. Die Reposition der dorsalen Fragmente geschieht indirekt
durch das Periost und Boden des Extensorenretinakulums (ungenau als Ligamentotaxis bezeichnet). Gegebenenfalls können nicht reponierbare dorsale
Fragmente durch kleine dorsale Zugänge reponiert und fixiert werden.
Unter intraoperativer Bildwandlerkontrolle können intraartikulär verlaufende
Frakturen ohne Gelenkseröffnung reponiert und fixiert werden. Hierfür ist eine
exakte präoperative Planung unerlässlich. Die Indikation für die Computertomographie ist bei intraartikulären Frakturen grosszügig zu stellen. Die gelenksnahe subchondrale Schraubenlage ist vor allem bei Verwendung von
unidirektionalen Implantaten intraoperativ peinlich genau zu kontrollieren, um
die extraartikuläre Schraubenlagen zu verifizieren. Der M. pronator quadratus
Mark A. Rudin
Abb. 2
muss nicht zwingend zur Frakturdarstellung durchtrennt werden, in gewissen
Fällen kann er auch geschont werden, indem die Platte unter den Muskel
geschoben wird (Abb. 2 ).
Winkelstabile Implantate sind in aller Munde und finden ein zunehmende
Verbreitung. Am distalen Radius erfüllt das Prinzip des Fixateur interne die
erforderliche mechanische Stabilität, die palmare Plattenlage ist biologisch
schonender als die dorsale.
Zur Versorgung der distalen instabilen Radiusfraktur stellt die palmare winkelstabile Plattenosteosynthese eine anspruchsvolle, ausgereifte biomechanisch vorteilhafte Technik dar.
Kurt P. Käch
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Congress Topics
Minimal invasive Plattenosteosynthese zur Behandlung der
lateralen Malleolarfraktur
Eine biologisch günstige Alternative zum herkömmlichen offenen Standardverfahren
Christian Marazzi, christian.marazzi@h-ju.ch
Jörg Peltzer, joerg.peltzer@h-ju.ch
Abb. 1
Abb. 2
Einführung
In den letzten Jahren haben sich die Anwendungen minimalinvasiver Techniken durch neue winkelstabile, präformierte Implantate an der unteren Extremität erfolgreich etabliert. So hat die distale Plattenosteosynthese bei
extrartikulären Frakturen der Tibia eine Renaissance erlebt. Für die häufigen
Malleolarfrakturen gilt weiterhin als Standardverfahren der offene Zugang
zur distalen Fibula mit anatomischer Rekonstruktion, wenn möglich interfragmentärer Kompression und Fixation über kleindimensionierte Platten.
Nichtsdestotrotz führt diese offene Technik mit subkutaner Plattenlage der
distalen Fibula vor allem bei Risikofaktoren wie PAVK, CVI, Diabetes mellitus
und ausgeprägtem Unfall- oder Operationstrauma nicht selten zu Wundheilungsstörungen. Der Verlauf wird häufig erschwert durch Hautnekrosen und
Infekten bis auf das Implantatlager, die Reinterventionen, Langzeithospitalisationen und allenfalls eine vorzeitige Materialentfernung bedingen können. Aus
diesen Gründen haben wir seit einem Jahr ein minimalinvasives Konzept zur
Stabilisierung der distalen Fibula eingeführt.
Technik und Material
Die Patienten werden wie bis anhin in Rückenlage, mit Blutsperre je nach
Schwellung und Antibiotika-Prophylaxe standardmässig vorbereitet. Wichtig
ist, dass bei vorliegender Bi- oder Trimalleolärer Fraktur zuerst der mediale
Malleolus anatomisch refixiert wird. Dies kann wie üblich über einen kleinen
Zugang oder über eine minimalinvasive Schraubenosteosynthese (MISO)
durchgeführt werden.
Unter Bildwandler erfolgt die Planung der Plattenlänge und der zwei Inzisio
nen. welche die Frakturzone nicht tangieren sollten. Eine 3,5 mm winkelstabile Drittelrohrplatte aus Titan wird in der Funktion einer Überbrückungsplatte
etwas länger dimensioniert gewählt und der Form der Fibula entsprechend
modelliert. Die zwei Zugänge zur Fibula werden gewebeschonend vorbereitet
wobei bei der proximalen Inzision auf die Schonung des Nervus cutaneus
dorsalis intermedius geachtet werden muss. Die Drittelrohrplatte wird von
distal nach Tunnelierung eingeschoben und zentriert auf der Fibulaspitze mit
einer winkelstabilen Schraube anfixiert. Über die eingeschraubte Bohrbüchse
Christian Marazzi
Abb. 3
im distalen Plattenteil kann nun die Reposition mittels Traktion und Rotation
unter BV-Kontrolle durchgeführt werden. Die Einstellung des Frakturspickels
kann von der proximalen Inzision digital ertastet werden. Die proximale Fixation der Drittelrohrplatte erfolgt entweder über eine komprimierende Kortikalisschraube oder direkt über winkelstabile Schrauben. Es sollten mindestens
zwei winkelstabile Schrauben auf beiden Seiten der Fraktur besetzt werden.
Resultat und Diskussion
Im Verlauf eines Jahres wurden 40 Patienten mit beschriebener MIPO-Technik versorgt. Das Patientengut mit obengenannten Risikofaktoren wies meist
bereits ausgeprägte Weichteilprobleme auf, bei z.T. komplexen, auch offen
Luxationsfrakturen. Auch bei noch nicht optimaler Abschwellung konnte frühzeitig die Osteosynthese durchgeführt werden, was für eine optimale indirekte
Frakturreposition vorteilhaft ist. Bei unbefriedigendem Repositionsresultat
durch eine Weichteilinterposition wurde bei einem Patienten auf ein offenes
Verfahren gewechselt. Die postoperativen erwarteten Wundheilungsstörungen konnten grossteils vermieden werden, Infekte und vorzeitige Metallentfernungen blieben aus. Radiologische Kontrollen der indirekten Reposition
zeigten gleichwertige Resultate wie bei der offenen Technik.
Der knöcherne Frakturdurchbau konnte in der 3-Monatskontrolle bestätigt
werden, ein Versagen der Osteosynthese wurde nicht festgestellt. Aufgrund
der klinisch guten Resultate wird die Technik nun auch auf Patienten ohne
Risikofaktoren angewendet. Die „no touch“-Technik der Frakturzone, mit Belassen des initialen heilungskompetenten Hämatoms, kann für die Frakturheilung nur vorteilhaft sein. Langzeitstudien mit grösseren Fallzahlen müssen
dies bestätigen.
Die Versorgung der Malleolarfrakturen ist meist den jungen Chirurgen als erster
Knocheneingriff zugesprochen. Mit Entwicklung minimalinvasiver Methoden
wird auch diese Frakturversorgung eher den versierten Traumatologen benötigen. Solche zunehmenden Defizite in der Ausbildung unserer Jungchirurgen
sollten durch andere Simulationen oder Konzepte ausgeglichen werden.
Jörg Peltzer
Sitzung 66 SGAUC/SSCGU, Freitag, 30.05.2008
13.00 – 14.00 Uhr, Room Singapore
Minimalinvasive Plattenosteosynthese (MIPO)
Time iS A GifT
first choice for the treatment of
unresectable and/or metastatic
malignant gastrointestinal stromal
tumors (GiST)
Novartis Pharma Schweiz AG, Monbijoustrasse 118, Postfach, 3001 Bern, Tel. 031 377 51 11
F747
Glivec® (Imatinib): C: Film-coated tablets containing 100 mg (scored) and 400 mg imatinib mesilate. I: Ph+ chronic myeloid leukemia (CML): chronic phase, accelerated phase and blast crisis. Ph+ acute
lymphoblastic leukaemia (ALL) in adults, in combination with standard chemotherapy. Atypical myelodysplastic/myeloproliferative diseases (MDS/MPD) with eosinophilia and platelet-derived growth
factor (PDGF) receptor mutations or gene rearrangements in adults. Unresectable and/or metastatic malignant gastrointestinal stromal tumors (GIST) in adults. Unresectable, recurrent or metastatic
dermatofibrosarcoma protuberans (DFSP) in adults. D: CML adults: 400 mg/d in chronic phase and 600 mg/d in blast crisis and accelerated phase as single dose. Dose increase from 400 to 600 mg/d,
or from 600 to 800 mg/d (divided in 2 doses of 400 mg in the morning and in the evening) in absence of severe adverse drug reactions in case of disease progression, failure to achieve a satisfactory
haematological response after > 3 months of treatment, absence of a cytogenic response after 12 months of treatment. CML children (≥ 3 years) and adolescents: chronic phase 260 mg/m2/d (max.
400 mg); accelerated phase and blast crisis 340 mg/m2/d (max. 600 mg). Calculated dose should be rounded up or down to the nearest 100 mg (in children < 12 years to the nearest 50 mg). MDS/
MPD: 400 mg/d. ALL: 600 mg/d, in combination with standard chemotherapy. GIST: 400 mg/d. In absence of adverse effects and if tests have demonstrated an unsatisfactory response to therapy an
increase to 600 mg/d is possible. DFSP: 400 mg/d, dose may be increased to 800 mg/d, as needed. CML/GIST: Withheld treatment if severe non-haematological adverse reactions develop, if bilirubin
increases to > 3 times or transaminases to > 5 times ULN. Dose reduction or discontinuation of treatment in patients with severe neutropenia and thrombocytopenia. Details see Swiss Compendium
of Drugs. CI: Hypersensitivity to the active substance or any of the excipients. PC: Complete blood count weekly during the first month, every 2 weeks during the second month and subsequently
as required. Determine liver function before the start of the treatment and at monthly intervals or as required. Adjust dose if necessary. Caution when combined with chemotherapy or concomitant
administering paracetamol. Avoid concurrent use of CYP3A4 inducers. Fluid retention may occur (weight control). Caution in patients with severe cardiac failure or glaucoma. Occurrence of congestive
heart failure. Close monitoring required in patients with cardiovascular risk factors or manifest heart disease. Monitor for gastrointestinal symptoms at the start of therapy. Closely monitor TSH levels in
thyroidectomy patients undergoing levothyroxine replacement. Details see Swiss Compendium of Drugs. IA: CYP3A4 inhibitors, CYP3A4 inducers, CYP3A4 substrates (e.g. simvastatin, benzodiazepines,
dihydropyridine calcium antagonists, other HMG-CoA reductase inhibitors, ciclosporin, pimozide), CYP2D6, CYP2C9, CYP2C19 and paracetamol. UE: Very common: neutropenia, thorombocytopenia,
anaemia, headache, nausea, vomiting, diarrhoea, dyspepsia, abdominal pain, periorbital oedema, dermatitis/eczema/rash, muscle spasm and cramps, musculoskeletal pain and arthralgia, fluid
retention and peripheral oedema, fatige; Common: febrile neutropenia, anorexia, weight gain, light-headedness, taste disturbance, paraesthesia, insomnia, conjunctivitis, increased lacrimation, blurred
vision, epistaxis, dyspnoea, abdominal distension, flatulence, constipation, gastro-oesophageal reflux, mouth ulceration, increased hepatic enzymes, facial oedema, eyelid oedema, pruritus, erythema,
dry skin, alopecia, night sweats, joint swelling, pyrexia, weakness, chills; Uncommon: sepsis, pneumonia, herpes simplex, herpes zoster, upper respiratory tract infection, gastroenteritis, pancytopenia,
bone marrow depression, dehydration, hyperuricaemia, hypokalaemia, increased appetite, reduced appetite, gout, hypophosphataemia, weight loss, depression, anxiety, reduced libido, cerebral haemorrhage, syncope, peripheral neuropathy, hypoaesthesia, somnolence, migraine, impairment of memory, eye irritation, subconjunctival haemorrhage, dry eye, dizziness, tinnitus, cardiac failure, pulmonary oedema, tachycardia, haematoma, hypertension, hypotension, flushing, peripheral coldness, pleural effusion, cough, pharyngeal and other throat pain, acute respiratory failure, gastrointestinal
haemorrhage, melaena, ascites, gastric ulcer, gastritis, eructation, dry mouth, jaundice, hepatitis, hyperbilirubinaemia, petechiae, contusion, increased sweating, urticaria, onychoclasis, photosensitivity
reaction, purpura, hypotrichosis, cheilitis, skin hyperpigmentation, skin hypopigmentation, psoriasis, exfoliative dermatitis and bullous eruptions, sciatica, joint and muscle stiffness, renal failure, renal
pain, increased urinary frequency, haematuria, gynaecomastia, breast enlargement, scrotal oedema, menorrhagia, nipple pain, sexual dysfunction, malaise, haemorrhage, increases in blood levels of
alkaline phosphatase, creatine phosphokinase, creatinine and lactic dehydrogenase. Rare and Very rare: see Swiss Compendium of Drugs. P: Scored film-coated tablets containing 100 mg imatinib:
60*, Film-coated tablets containing 400g imatinib: 30*, Sales category: B. * admitted by the health insurance. For further information, please consult the Swiss Compendium of Drugs.
Congress Topics
Die elektive Versorgung des infrarenalen Aortenaneurysmas
Florian Dick*, florian.dick@insel.ch
Jürg Schmidli, juerg.schmidli@insel.ch
Die elektive Versorgung des abdominalen Aortenaneurysmas (AAA) wurde in
den frühen 1950ern in der Absicht eingeführt, die zugehörige Mortalität im
Falle einer Aortenruptur zu senken. Das Komplikations- und Mortalitätsrisiko des offenen Aortenersatzes (offener Aortenrepair oder OAR) selbst darf
aber nicht unterschätzt werden. Typische Raten für operative Morbidität und
Mortalität liegen in Multizenterserien auch heute noch bei 10 – 15%, bzw. 3
– 6%1.
In den frühen 1990ern hat Parodi die AAA Chirurgie mit einem Bericht über
ein fundamental neues Konzept revolutioniert2. Der endovaskuläre Aortenrepair (EVAR) liess mit seinem minimal-invasiven Therapieansatz grosse Fortschritte bezüglich Sicherheit erhoffen. Entsprechend schnell sind nach kurzer
Evaluation auch die ersten kommerziellen Implantate auf den freien Markt
gekommen (1999).
Das Rupturrisiko eines AAA steigt gemäss Poiseuille-Gesetz exponentiell
mit seinem Durchmesser. Doch wann nimmt dieses Risiko überhand? Randomisierte Studien zeigen, dass es sicher ist (und viel kosteneffektiver), mit
der elektiven Versorgung bis zu einem Durchmesser von 55 mm zu warten
(bei Frauen etwas weniger)3, 4. Für grössere AAA gibt es keine randomisierten
Vergleiche zwischen OAR und Abwarten. Es bleibt unklar, wie viele und v.a.
welche AAA Patienten eher an Begleiterkrankungen sterben. So hat der EVAR
Trial 2 z.B. gezeigt, dass EVAR bei Patienten mit prohibitivem Operationsrisiko keine Vorteile im Vergleich zu Abwarten bringt, sondern nur Komplikationen5. Es ist wichtig, zu verstehen, dass die heutige Indikationspraxis also auf
der Erkenntnis beruht, dass man mit der AAA Versorgung ohne Nachteile bis
zu einem AAA Durchmesser von 55mm warten kann, und nicht etwa darauf,
dass es gesicherte Daten gäbe, dass die Versorgung von grösseren AAA eine
Verlängerung der Lebenserwartung bringt. In die individuelle Therapieplanung müssen Lebenserwartung, Begleiterkrankungen und Operationsrisiko
des Patienten genauso eingehen wie AAA Anatomie und lokale Expertise.
EVAR und OAR sind mehrfach randomisiert verglichen worden6, 7, und in allen
Studien zeigt sich wie erwartet ein perioperativer Überlebensvorteil für EVAR.
Aber: Bezüglich Langzeitüberleben ist bisher keine Methode messbar besser,
und in den heutigen Kostenstrukturen ist EVAR deutlich teurer6, 7. Ausserdem
führt EVAR vermehrt zu Zweiteingriffen, die in ihrer Komplexität allerdings
meist deutlich weniger schwer wiegen als Zweiteingriffe nach OAR. EVAR
führt unter Umständen nicht zu einer kompletten Ausschaltung des Aneurysmas, was mit einem minimalen Rest-Rupturrisiko assoziiert ist. Häufige
Nachkontrollen sind darum indiziert. OAR wird zwar seltener von Anastomosenaneurysmata begleitet (die auch rupturieren können), ist dafür aber häufiger mit Graftinfekten assoziiert, die ihrerseits ein hohes Sterberisiko bergen.
Insgesamt sind Lebensqualität und körperliche Fitness langfristig nach beiden Eingriffen wahrscheinlich ähnlich8.
Florian Dick
EVAR und OAR zielen auf verschiedene Populationen, die nur eine beschränkte Schnittmenge aufweisen. Anatomische Kriterien für EVAR betreffen vor allem Form und Wandqualität des proximalen Aneurysmahalses (die
Verankerungszone des Implantates) sowie Voraussetzungen des Gefässzugangs und schliessen aktuell rund ein Drittel der AAA Patienten von EVAR
aus9. Dafür erweitert EVAR das Behandlungsspektrum bei älteren und kränkeren Patienten, für die eine offene Operation nicht in Frage kommt. Beide
Technologien müssen darum eher im Sinne einer Therapieergänzung als im
Sinne von Konkurrenzverfahren verstanden werden, auch wenn technische
Modifikationen den Einsatz von EVAR wohl zunehmend ausweiten werden.
Ängste vor einer überproportionalen Zunahme von technisch schwierigen
Fällen beim OAR und deren Auswirkung auf das Training und die Erfahrung
von angehenden Chirurgen sind aus der minimal-invasiven Revolution der
Gallenblasenchirurgie bekannt und berechtigt. Umso mehr wird sich die AAA
Chirurgie in spezialisierten Zentren konzentrieren müssen. Die Qualität von
OAR steigt direkt mit der jährlichen Fallzahl10. Entsprechend können in „Centres of Excellence“ operative Mortalitätsraten von deutlich unter 1% erreicht
werden8, was leichtfertige Indikationen für EVAR in Frage stellen muss. Solche Zahlen dürfen Patienten nicht länger vorenthalten werden, bevor sie sich
für Methode und Ort der Behandlung entscheiden.
*FD ist zurzeit Stipendiat des Schweizerischen Nationalfonds (PBBSB120858) und der Lichtensteinstiftung Basel
Literatur
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Costin et al., J Vasc Surg 2006; 43: 915-20
Parodi et al., Ann Vasc Surg 1991; 5: 491-9
UK Small Aneurysm Trial, NEJM 2002; 346(19): 1445-1452
ADAM Trial, N Engl J Med 2002; 346: 1437-44
EVAR Trial 2, Lancet 2005; 365: 2187-92
EVAR Trial 1, Lancet 365: 2179-2186
Prinssen et al., N Engl J Med 2004; 351: 1607-18
Dick et al., World J Surg 2008, in press
Carpenter et al., J Vasc Surg 2001; 34: 1050-4
Eckstein et al., Eur J Vasc Endovasc Surg 34: 260-266
Jürg Schmidli
Congress Topics
Laparoscopie abdominale: possibilités et limites
Hervé Probst, herve.probst@chuv.ch
Nicolas Demartines, demartines@chuv.ch
Le développement de la chirurgie dite «minimal invasive» a permis une diminution de la morbidité et de la mortalité, ainsi que des taux d’infection et
des séjours hospitaliers1. Lorsque les principes oncologiques conventionnels
sont réspéctés2, l’abord laparoscopique est devenu un standard et les implantations pariétales ne sont pas plus élevées qu’en abord ouvert avec une
incidence de 0.72%3. De plus, la réduction du traumatisme pariétal en laparoscopie tempère la réponse immunitaire4.
La chirurgie laparoscopique avancée en oncologie
Œsophage
La survie à 5 ans du cancer de l’œsophage augmente grâce aux traitements
multimodaux de 5 à 10%, jusqu’à 25 voire 30% à 5 ans actuellement5. Divers
abords mini-invasif sont en voie d’évaluation comme l’abord trans-hiatal totalement laparoscopique avec anastomose cervicale, ou le double abord abdominal et thoracique en scopie combinée ou non avec une voie ouverte. La
faisabilité de l’oesophagectomie trans-hiatale par laparoscopie est montrée
avec l’absence de complications majeures6. L’oesophagectomie par laparoscopie et thoracoscopie offre une mortalité de 1.4%, et une morbidité de 32%
dont 11.7% de fuite, comme en chirurgie ouverte7. L’approche laparoscopique permet de prélever un nombre similaire de ganglions, tout en emportant
la tumeur dans sa totalité avec des marges de résection adéquate8.
Foie
Les premières résections laparoscopiques non-anatomiques et anatomiques
ont été décrites en 1991 et 19969. Depuis, les principales controverses oncologique sont les risques de résection incomplète, d’embolie gazeuse, de
saignement difficile à gérer et de temps opératoires prolongés. Cependant, il
n’existe pas de différence de marge de résection positive entre les groupes laparoscopique et ouvert, avec une mortalité post-opératoire de moins de 5%9.
L’utilisation de l’ultrason per-opératoire est indispensable en laparoscopie
pour préciser les rapports entre tumeur et structures vasculaires et biliaires10.
Par ailleurs, c’est l’exposition inadéquate du foie qui entraîne les conversions
pour hémorragie (23%)11.
La sélection des patients pour une résection hépatique par laparoscopie se
base sur la localisation et la taille de la lésion12. Les petites lésions superficielles ou périphériques essentiellement dans les segments II-III ou antérieurs
(segment IV, V, VI) constituent de bonnes indications12.
Pancréas
Le staging par laparoscopie n’est plus largement utilsé13 car le CT-Scan et/ou
l’IRM en ont limité l’importance. La pancréatectomie distale et l’énucléation
sont les gestes les plus décrits par laparoscopie14. Le nombre de pancréatectomies distales par laparoscopie publiées dépasse les 200 cas avec une
mortalité < 1%, 16% de fistule et 2% d’hémorragies15, et une diminution du
séjour hospitalier16.
La résection céphalique du pancréas par laparoscopie est actuellement très
controversée et son bénéfice n’est pas démontré, cette intervention restant
limitée à un petit nombre de centres très spécialisés17. Les complications sont
similaires à la chirurgie ouverte18. Aucune étude n’a validé la résection laparoscopique pancréatique oncologique, et les lésions intra-canalaire, précurseurs de cancer invasif, pourraient être une indication de choix.
Rectum
Alors que les bénéfices de la laparoscopie sont démontrés pour la colectomie, les résultats pour le cancer de rectum proviennent d’études cohortes
et des résultats prospectifs randomisés ne seront publiée que l’an prochain.
Sont décrit, un taux de conversion de 20%, une morbidité de 25.4%, et 7.6%
de fuite anastomotique. La mortalité post-opératoire est de 0.9% et le séjour
hospitalier moyen de 6.8 jours19. La laparoscopie est associée à une diminution du séjour hospitalier et du temps de reprise de transit, une morbidité
plus basse ou identique et des temps opératoires augmentés20, 21. Quelques
doutes persistent sur une possible positivité de marge de résection radiaire22.
Pour préciser les indications de la laparoscopie dans le cancer du rectum,
l’American College of Surgeons Oncology Group élabore une étude prospective randomisée.
Hervé Probst
86 swiss knife 2008; special edition
Nicolas Demartines
Congress Topics
Conclusion
La chirurgie laparoscopique est devenue le standard pour de nombreuses interventions y compris en chirurgie oncologique. Les principaux inconvénients
des techniques mini-invasive restent l’augmentation du temps opératoire et la
nécessité d’une grande expérience chirurgicale.
Références
1. N.J. Soper, L.M. Brunt, K. Kerbl. Laparoscopic general surgery. N Engl J Surg 1994;
330: 409-419
2. F.L. Greene, K.W. Kercher, H. Nelson, C.M. Teigland, A.M. Boller. Minimal access
cancer management. Cancer J Clin 2007; 57: 130-146
3. R. Veldkamp, M. Gholghesaei, H.J. Bonjer, et al. Laparoscopic resection of colon
cancer. Consensus of the European Association of Endoscopic Surgeons (EAES).
Surg Endosc 2004; 18: 1163-1685
4. M.J. Trockel, M. Bessler, M.R. Treat et al. Preservation of immune response after
laparoscopy. Surg Endosc 1994; 8: 1385-1387
5. S. Avital, N. Zundel, S. Szomstein, R. Rosenthal. Laparoscopic transhiatal esophagectomy for esophageal cancer. Am J Surg 2005; 190: 69-74
6. A.L. De Paula, K. Hashiba, E.A. Ferreira, et al. Laparoscopic trans-hiatalesophagectomy with esophagogastroplasty. Surg Laparosc Endosc 1995; 5: 1-5
7. J.D. Luketich, M. Alvevo-rivera, P.O. Buenaventura, et al. minimally invasive esophagectomy :outcomes in 222 patients. Ann Surg 2003; 238: 486-494
8. A.De Hoyos, V.R. Litle, J.D. Luketich. Minimally invasive esophagectomy. Surg Clin
N Am 2005; 85: 631-647
9. T. Mala, B. Edwin. Role and limitations of laparoscopic liver resection of colorectal
metastases. Dig Dis 2005; 23:142-150
10. L. Biertho, A. Waage, M. Gagner. Hepatectomies sous laparoscopie. Ann Chir 2002;
127: 164-170
11. G. Belli, C. Fantini, A. d’Agostino, A. Belli, N. Russolillo. Laparoscopic liver resection
for hepatocellular carcinoma (HCC) in cirrhotic patients. HPB 2004; 6 (4) 236-246
12. M. Lesurtel, D. Cherqui, A. Laurent, C. Tayar, P.L. Fagniez. Laparoscopic versus
open left lateral hepatic lobectomy: a case-control study. J Am Coll Surg 2003; 196:
236-242
13. A.L. Warshaw, J.E. Tepper, W.U. Shipley. Laparoscopy in the staging and planning of
therapy for pancreatic cancer. Am J Surg 1986; 151: 76-80
14. K. Takaori, N. Tanigawa. Laparoscopic pancreatic resection :the past, present and
future. Surg Today 2007; 37: 535-545
15. A. Ayav, L. Bresler, L. Brunaud, P. Boissel. Laparoscopic approach for solitary insulinoma : a multicentre study. Langenbecks Arch Surg 2005; 390: 134-140
16. V. Velanovich. Case-control comparison of laparoscopic versus open distal pancreatectomy. J Gatrointest Surg 2006; 10: 95-98
17. C. Staudacher, E. Orsenigo, P. Baccari, S. Di Palo, S. Crippa. Laparoscopic assisted
duodenopancreatectomy. Surg Endosc 2005; 19: 352-356
18. C. Pananivelu. Art of laparoscopic surgery – text book and atlas. Coimbatore: Jaya
publication 2005; P911-640
19. A.M. Lacy, D.M. Momblan, E. Mans, R. Corcelles, R. Bravo, A. Ibarzabal. Laparscopic surgery in the treatment of rectum cancer. Surg endosc 2005; 19: S163
20. F. Gao, YF Cao, LS Chen. Meta-analysis of short-term outcomes after laparoscopic
resection for rectal cancer. Int J Colorectal Dis 2006; 21: 652-656
21. O. Aziz, V. Constantinides, P. Tekkis, et al. Laparoscopic versus open surgery for
rectal cancer: a meta-analysis. Ann Surg Oncol 2006; 13: 413-424
22. P.J. Guillou, P. Quirke, H. Thorpe, et al. Short-term endpoints of conventionnal versus laparoscopic-assisted surgery in patients with colorectal cancer(MRC CLASSICC trial): multicentre, randomised controlled trial. Lancet 2005; 365: 1718-1726
4RAUMA
(OFFMANN))
%XTERNAL&IXATION3YSTEM
-ODULAR3YSTEMFOR
s,ONG"ONES
s0ELVIS
Stryker Osteonics SA
Swiss Sales & Distribution
Ch. des Aulx 5
1228 Plan-les-Ouates / Geneva
Switzerland
Phone: +41 22 884 01 08
Fax: +41 22 884 01 09
www.stryker.ch
Congress Topics
Stellenwert der Laparoskopie beim adhäsionsbedingten
Dünndarmileus
Valentin Neuhaus, valentin.neuhaus@spital-limmattal.ch
Matthias Turina, matthias.turina@spital-limmattal.ch
Othmar Schöb, othmar.schoeb@spital-limmattal.ch
Der adhäsionsbedingte Dünndarmileus ist eine häufige Form des mechanischen Ileus und führt bei rund 35% aller voroperierten Patienten innert 10
Jahren zur Rehospitalisation1 und in 2 – 5% zur sekundären operativen Adhäsiolyse2. Postoperative Verwachsungen reichen von der einfachen Bride
bis zum ausgedehnten „Verwachsungsbauch“, wobei die Art und Grösse des
vorangehenden Eingriffes nicht zwangsläufig mit der Ausdehnung der Adhäsionen korreliert. Eine Häufung intraabdominaler Adhäsionen konnte dennoch
z.B. in der offenen kolorektalen Chirurgie nachgewiesen werden, bei welcher
bis 30% aller Patienten innerhalb von 4 Jahren aufgrund adhäsionsbedingter
Komplikationen behandelt werden müssen3. Bei Relaparotomien konnten in
bis zu 90% Adhäsionen festgestellt werden, wobei aber die Mehrzahl der Patienten asymptomatisch verbleibt. Pathophysiologisch wird in erster Linie die
intraoperative Denudierung des Mesothels mit überbrückender Fibrinbildung
und nachfolgender Neovaskularisierung als ursächlich erachtet4.
Die Diagnostik des adhäsionsbedingten Ileus ist in der Regel unproblematisch, wobei die Menge, Lokalisation und das Ausmass intestinaler Adhäsionen präoperativ mittels Sonographie und CT kaum abschätzbar sind und
selten mit dem intraoperativen Befund korrelieren. Von Adhäsionen betroffen
sind in abnehmender Wahrscheinlichkeit das Omentum majus (68%), Dünndarm (67%), die Bauchwand (45%), das weibliche Genitale (23%), das Kolon
(41%), die Leber (34%), der Magen (20%), das Retroperitoneum (14%) und
zuletzt die Milz (9%)5.
Trotz intensiver Forschungsbemühungen existieren zum heutigen Zeitpunkt
keine Medikamente/Produkte, mit welchen eine signifikante Reduktion der
Rate adhäsionsbedingter Reoperationen erreicht werden konnte, sodass in
der Schweiz solche Substanzen ausserhalb von Studienprotokollen kaum
Einsatz finden.
In den letzten Jahren wurde der Stellenwert der Laparoskopie sowohl in Bezug
auf die ursächliche Vermeidung von Adhäsionen wie auch deren Behandlung
mehrfach diskutiert. Trotz ileusbedingt oftmals ungünstiger Laparoskopiebedingungen mehren sich Berichte über erfolgreiche laparoskopische Adhäsiolysen und Bridenlösungen, womit durch Vermeidung der Relaparotomie
potentiell ein günstigeres Resultat erreicht werden konnte6, 7. Hinzu kommt
der meist komplikationsärmere Verlauf mit rascherem Ingangkommen der
Darmtätigkeit, kürzeren Hospitalisationszeiten und geringerer Mortalität. Eine
dadurch bedingte Kostenreduktion konnte bisher nicht bewiesen werden,
scheint aber plausibel. Das gerne zitierte Argument der möglichen iatrogenen
Darmläsion bei Einbringen des ersten Trokares unter Ileusbedingungen verdient insbesondere bei geringer Laparoskopieerfahrung des Operateurs Beachtung, wenn auch diesbezüglich konkrete Angaben in der Literatur fehlen.
Aufgrund der generellen Ausbreitung der Laparoskopie, von welcher bei Bedarf jederzeit auf ein offenes Vorgehen gewechselt werden kann, dürfte in Zu-
Valentin Neuhaus
Matthias Turina
kunft eine Ausweitung der Indikationsstellung zum laparoskopischen Vorgehen beobachtet werden. In unserem eigenen Patientengut werden Patienten
mit vermutlich adhäsionsbedingtem Ileus in aller Regel laparoskopisch angegangen, wobei präoperativ insbesondere bei fortgeschrittenem Patientenalter
mit Möglichkeit eines tumorbedingten Ileus ein CT durchgeführt wird. Wenn
sich intraoperativ Adhäsionen als Ileusursache bestätigen, wird wenn immer
möglich versucht, diese laparoskopisch zu lösen. Eine Untersuchung unserer
Erfahrung der letzten 8 Jahre (vorgestellt am 95. Jahreskongress der Schweizerischen Gesellschaft für Chirurgie) bestätigt die durchwegs guten Resultate
dieses Vorgehens, wobei bis zwei Drittel aller Adhäsiolysen laparoskopisch
durchgeführt werden konnten. Entscheidend waren die „laparoskopische
Routine“ des Operateurs sowie die Ausdehnung der intestinalen Adhäsionen,
wobei Patienten mit einfachen Briden oder vereinzelten Adhäsionen erwartungsgemäss häufiger erfolgreich laparoskopisch behandelt werden konnten
als solche mit ausgedehnten Verwachsungen. Zusammenfassend stellt die
Laparoskopie unserer Ansicht nach einen guten ersten Schritt in der Behandlung des adhäsionsbedingten Ileus dar, welcher oftmals erfolgreich durchgeführt werden und damit eine Reduktion der perioperativen Morbidität und
Mortalität herbeiführen kann.
Literatur
1. Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS, Menzies D, McGuire A,
Lower AM, Hawthorn RJ, O‘Brien F, Buchan S, Crowe AM. Adhesion-related hospital
readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet
1999; 353: 1476-1480
2. Beck DE, Opelka FG, Bailey HR, Rauh SM, Pashos CL. Incidence of small-bowel obstruction and adhesiolysis after open colorectal and general surgery. Dis Colon Rectum
1999; 42: 241-248
3. Parker MC, Wilson MS, Menzies D, Sunderland G, Thompson JN, Clark DN, Knight
AD, Crowe AM. Colorectal surgery: the risk and burden of adhesion-related complications. Colorectal Dis 2004; 6: 506-511
4. Raftery AT. Regeneration of parietal and visceral peritoneum. A light microscopical
study. Br J Surg 1973; 60: 293-299
5. Luijendijk RW, de Lange DC, Wauters CC, Hop WC, Duron JJ, Pailler JL, Camprodon
BR, Holmdahl L, van Geldorp HJ, Jeekel J. Foreign material in postoperative adhesions. Ann Surg 1996; 223: 242-248
6. Bailey IS, Rhodes M, O‘Rourke N, Nathanson L, Fielding G. Laparoscopic management of acute small bowel obstruction. Br J Surg 1998; 85: 84-87
7. Majewski WD. Long-term outcome, adhesions, and quality of life after laparoscopic
and open surgical therapies for acute abdomen: follow-up of a prospective trial. Surg
Endosc 2005; 19: 81-90
Othmar Schöb
Congress Topics
Y a-t-il encore une place pour la chirurgie anti-reflux en
2008?
Axel Andres, axel.andres@ehnv.ch
Michel Erne, michel.erne@ehnv.ch
Le reflux gastro-oesophagen (RGO) est un problème courant dont le coût
annuel direct pour la prise en charge est estimé à 9 milliards de dollars aux
USA1. Le traitement du reflux gastro-oesophagien, initialement accessible à la
chirurgie seule, a été profondément modifié par l’arrivée sur le marché de médicaments antacides puissants comme les antagonistes des récepteurs H2
(anti-H2) au début des années 80, puis des inhibiteurs de la pompe à proton
(IPP) à la fin des années 80. Avec maintenant 20 ans de recul, ces médicaments ont prouvé leur innocuité et permettent des traitements au long cours
du RGO. L’incapacité à inhiber la production d’acide à l’aide d’un traitement
d’IPP bien conduit est inhabituel et les échecs d’un tel traitement doivent faire
rechercher une autre pathologie qu’un RGO simple. Reste-t-il donc à l’ère
des IPP une place pour la chirurgie?
Concernant la métaplasie de Barrett (MB), une ERP n’a pas montré de différence de prévalence de MB avant et après traitement entre le groupe traité
par IPP et le groupe traité chirurgicalement4. Cependant, une étude non-randomisée n’incluant que des patients sans MB a montré que l’incidence de MB
à 1 an était de 14.5% dans le groupe traité par IPP et de 0% dans le groupe
traité chirurgicalement8.
Peu d’études randomisées prospectives (ERP) ont comparé les résultats de la
chirurgie anti-reflux et du traitement médicamenteux2-6. Les recommandations
se fondant sur des degrés d’évidence acceptable se basent principalement
sur 3 ERP qui n’ont pas montré de supériorité de la chirurgie sur le traitement
médicamenteux à long terme (> 1 an) en cas de posologie d’IPP ininterrompue et adaptée. Il y a néanmoins un trend statistiquement non significatif en
faveur de la chirurgie pour contrôler les symptômes dans 2 études sur 3 et la
troisième montre à court terme un meilleur contrôle des symptômes et une
meilleure qualité de vie6.
Les patients réfractaires au traitement d’IPP bien conduit sont aujourd’hui rares. Un problème particulier est cependant celui du reflux, dont les IPP ne traitent que la composante acide. Un patient dont la régurgitation est la plainte
principale ne sera efficacement traité que chirurgicalement. Le problème de la
régurgitation biliaire déborde le cadre de cet exposé car, bien qu’associé dans
certaines études à la MB11, 12 demande des chirurgies de dérivations autres
que les procédures anti-reflux13.
Deux éléments s’opposent à ce trend en faveur de la chirurgie:
1. La reprise d’un traitement médicamenteux présent jusqu’à 60% des patients opérés5.
2. La survenue d’effets secondaires post-opératoires dont le plus cité est la
dysphagie au delà de 3 mois qui survient dans 4.5% des ERP2, 6.
Devant la similitude des résultats entre chirurgie et traitement médicamenteux, plusieurs auteurs ont proposé de n’offrir une intervention qu’aux patients présentant des complications du reflux tels que sténose, métaplasie de
Barrett, des symptômes de reflux malgré un traitement médicamenteux bien
conduit ou la non-adhérence à un traitement médicamenteux.
La sténose peptique est aujourd’hui principalement traitée par endoscopie.
Les IPP préviennent efficacement la survenue de nouvelles sténoses7 et la
chirurgie n’est pas une indication absolue dans ce contexte.
L’effet de la chirurgie sur l’incidence du cancer oesophagien est difficile à
démontrer en raison de sa faible prévalence. La seule ERP mentionnant ce
sujet n’est pas assez puissante pour en tirer des conclusions5 et 2 études de
cohorte n’ont pas montré de supériorité de la chirurgie par rapport au traitement médical dans l’incidence du cancer oesophagien9, 10.
La dernière indication est la non adhérence à un traitement médicamenteux
au long cours, soit par souhait du patient, soit par non-compliance.
Si l’indication à la chirurgie est retenue, faut-il réaliser une voie ouverte ou
une laparoscopie? Bien que certaines études prospectives aient montré un
taux plus élevé de dysphagie prolongée post-opératoire avec la laparoscopie14,15, les données montrent globalement une similitude de résultats entre
voie ouverte et laparoscopie16, 17.
Depuis 2000 la FDA a laissé commercialiser une nouvelle voie : la voie gastroentérologique ou endoscopique. Il existe plusieurs appareils dont les principes sont soit une plicature sous-muqueuse ou totale, une cicatrisation dirigée
du sphincter inférieur de l’œsophage (SIO) ou l’injection de polymères dans le
SIO. Bien que les méthodes de plicature endoscopiques aient montré une certaine efficacité par rapport au placebo, elles sont actuellement certainement
bien moins efficace que la chirurgie mais les études sont insuffisantes18,19.
Axel Andres
Michel Erne
Congress Topics
Conclusion: en 2005 le département américain de la santé a publié une revue qui conclut que les traitements chirurgical et médical ont une efficacité
similaire et qu’il n’y a pas de données suffisantes pour favoriser un traitement
chirurgical pour prévenir un Barret ou un cancer oesophagien20. Toutefois,
la même revue admet que les études qui comparent directement ces traitements ainsi que le nombre de patients sont faibles. Au delà des statistiques,
il faut remarquer plusieurs résultats de ces mêmes ERP qui convergent vers
un léger bénéfice de la chirurgie dans le traitement au long cours des symptômes.
L’indication à une chirurgie anti-reflux reste certainement, aujourd’hui encore,
le résultat d’une discussion individuelle avec un patient peu satisfait d’un traitement médicamenteux.
Références
1. Sandler, RS, Everhart, JE, Donowitz, M, et al., The burden of selected digestive
diseases in the United States. Gastroenterology, 2002; 122(5): 1500-11
2. Mehta, S, Bennett, J, Mahon, D, et al., Prospective trial of laparoscopic nissen
fundoplication versus proton pump inhibitor therapy for gastroesophageal reflux disease: Seven-year follow-up. J Gastrointest Surg, 2006; 10(9): 1312-6; discussion
1316-7
3. Lundell, L, Miettinen, P, Myrvold, HE, et al., Seven-year follow-up of a randomized
clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis. Br J Surg, 2007; 94(2): 198-203
4. Lundell, L, Miettinen, P, Myrvold, HE, et al., Continued (5-year) followup of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg, 2001; 192(2): 172-9; discussion 179-81
5. Spechler, SJ, Lee, E, Ahnen, D, et al., Long-term outcome of medical and surgical
therapies for gastroesophageal reflux disease: follow-up of a randomized controlled
trial. Jama, 2001; 285(18): 2331-8
6. Mahon, D, Rhodes, M, Decadt, B, et al., Randomized clinical trial of laparoscopic
Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux. Br J Surg, 2005; 92(6): 695-9
7. Klinkenberg-Knol, EC, Festen, HP, Jansen, JB, et al., Long-term treatment with
omeprazole for refractory reflux esophagitis: efficacy and safety. Ann Intern Med,
1994; 121(3): 161-7
8. Wetscher, GJ, Gadenstaetter, M, Klingler, PJ, et al., Efficacy of medical therapy and
antireflux surgery to prevent Barrett‘s metaplasia in patients with gastroesophageal
reflux disease. Ann Surg, 2001; 234(5): 627-32
9. Ye, W, Chow, WH, Lagergren, J, et al., Risk of adenocarcinomas of the esophagus
and gastric cardia in patients with gastroesophageal reflux diseases and after antireflux surgery. Gastroenterology, 2001; 121(6): 1286-93
10. Tran, T, Spechler, SJ, Richardson, P, et al., Fundoplication and the risk of esophageal
cancer in gastroesophageal reflux disease: a Veterans Affairs cohort study. Am J
Gastroenterol, 2005; 100(5): 1002-8
11. Wolfgarten, E, Putz, B, Holscher, AH, et al., Duodeno-gastric-esophageal reflux
– what is pathologic? Comparison of patients with Barrett‘s esophagus and agematched volunteers. J Gastrointest Surg, 2007; 11(4): 479-86
12. Csendes, A, Braghetto, I, Burdiles, P, et al., A new physiologic approach for the surgical treatment of patients with Barrett‘s esophagus: technical considerations and
results in 65 patients. Ann Surg, 1997; 226(2): 123-33
13. Mabrut, JY, Collard, JM, and Baulieux, J, [Duodenogastric and gastroesophageal
bile reflux]. J Chir (Paris), 2006; 143(6): 355-65
14. Bais, JE, Bartelsman, JF, Bonjer, HJ, et al., Laparoscopic or conventional Nissen
fundoplication for gastro-oesophageal reflux disease: randomised clinical trial. The
Netherlands Antireflux Surgery Study Group. Lancet, 2000; 355(9199): 170-4
15. Franzen, T, Anderberg, B, Wiren, M, et al., Long-term outcome is worse after laparoscopic than after conventional Nissen fundoplication. Scand J Gastroenterol,
2005; 40(11): 1261-8
16. Salminen, PT, Hiekkanen, HI, Rantala, AP, et al., Comparison of long-term outcome
of laparoscopic and conventional nissen fundoplication: a prospective randomized
study with an 11-year follow-up. Ann Surg, 2007; 246(2): 201-6
17. Nilsson, G, Wenner, J, Larsson, S, et al., Randomized clinical trial of laparoscopic
versus open fundoplication for gastro-oesophageal reflux. Br J Surg, 2004; 91(5):
552-9
18. Schwartz, MP and Smout, AJ, Review article: The endoscopic treatment of gastrooesophageal reflux disease. Aliment Pharmacol Ther, 2007; 26 Suppl 2: 1-6
19. Schwartz, MP, Wellink, H, Gooszen, HG, et al., Endoscopic gastroplication for the
treatment of gastro-oesophageal reflux disease: a randomised, sham-controlled trial. Gut, 2007; 56(1): 20-8
20. Ip, S, Bonis, P, Tatsioni, A, et al., Comparative effectiveness of management strategies for gastroesophageal reflux disease. US Agency for Healthcare Research and
Quality, 2005; 06-EHC003(December): www.ahrq.gov.
Einfach Clexane®
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mit oder ohne Lungenembolie (3), der instabilen A. p. und
des Nicht-Q-Wellen-Myokardinfarktes in Kombination mit
Acetylsalicylsäure (4). Thromboseprophylaxe im extrakorporalen Kreislauf bei der Hämodialyse (5). Dosierung: 1:
20–40 mg s.c. tägl. je nach Risiko. 2: 40 mg s.c. tägl. 3: 1 mg/
kg s.c 2 x tägl. oder 1.5 mg/kg s.c 1 x tägl. 4: 1 mg/kg s.c
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in der Schwangerschaft, i.m.-Verabreichung. Vorsichtsmassnahmen: spinale/epidurale Anästhesie, heparinind.
Thrombozytopenie, Leber- oder Niereninsuffizienz, ältere
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Schwangerschaft: Anwendung nur bei Notwendigkeit.
Unerwünschte Wirkungen: Blutungen und Ekchymosen/
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syst. Allergie, Vaskulitiden, Anstieg der Thrombozyten und
der Leberwerte. Interaktionen: Substanzen, welche die
Hämostase beeinflussen. Packungen: Fertigspritzen zu
20 mg/0.2 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml, 90 mg/
0.6 ml, 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml; Clexane® multi
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28.2.2008 10:55:51 Uhr
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Congress Topics
Stuhlinkontinenz
Selim Dinçler, dincler@mirox.ch
Peter Buchmann, peter.buchmann@waid.zuerich.ch
Die Stuhlkontinenz benötigt einen intakten Sphinkterapparat, ein dehnbares
Rektum und die neuronal gesteuerte Koordination der Muskelgruppen. Häufigste Ursache der Inkontinenz ist eine Sphinkterverletzung durch vaginale
Geburten. Die Altersverteilung zeigt zwei Gipfel: postpartale Manifestation
sowie nach zwei bis drei Dekaden, letzteres durch – hormonbedingte – Gewebsalterung. Männer sind seltener betroffen, meist nach Fistelspaltungen.
Eine schematische Auflistung der Ursachen zeigt Tabelle 1.
Die Diagnostik beginnt mit der Anamnese: Art und Menge (Tab. 2) sowie Umstände und Häufigkeit sollten gezielt erfragt werden. Narben können Hinweis
für eine traumatische oder iatrogene Ursache sein. Zeichen für einen Descensus perinei sind eine verstrichene Analfalte oder gar das Vorstehen der Analregion. Ein auslösbarer Anokutanreflex beweist die Integrität des N. pudendus und Plexus sacralis. Beim Pressen kann ein Rektumprolaps provoziert
werden. Die digitale Untersuchung soll auch die Funktion der Puborektalisschlinge prüfen. Von zentraler Bedeutung ist die Endosonographie. Sie zeigt
die Länge des Analkanals, Anatomie und Defekte des Sphinkterapparates
und allfällige okkulte Schäden. Zur Planung einer Sphinkterrekonstruktion ist
sie unverzichtbar.
Die Therapie führt oft schrittweise vom konservativen zum operativen Vorgehen. Zunächst muss durch Optimierung der Stuhlkonsistenz und -menge
eine problemlose Defäkation gewährleistet sein, ohne starkes Pressen oder
Diarrhöe. Ballastreiche Kost erhöht das Stuhlvolumen und vermindert so
den Pressakt. Quellmittel regulieren die Konsistenz. Je nach dem, mit wie
viel Flüssigkeit sie eingenommen werden, korrigieren sie dünne oder harte
Stühle. Stuhlregulantien beeinflussen die Transitzeit, Loperamid hemmt die
Darmperistaltik und erhöht den Analsphinktertonus. Regelmässiger Alkoholund Medikamentenkonsum sollten mitberücksichtigt werden.
Beckenbodentraining verbessert die Leistungsfähigkeit der intakten Muskelfasern. Biofeedback-Training hat den Vorteil, dass die Effekte der Übungen
direkt visualisiert werden.
Der isolierte Defekt des äusseren Schliessmuskels kann mit einer Sphinkterrekonstruktion behoben werden. Die Sphinkterenden werden schindelartig
angenähert und fixiert. Der Erfolg wird hauptsächlich dem Stenosierungseffekt zugeschrieben. Leider verschlechtert sich die Kontinenz im Laufe der
Jahre. Flankierende konservative Massnahmen können Symptome hinauszögern oder verhindern.
Die sakrale Neurostimulation (SNS) oder als Synonym -modulation (SNM) bedarf eines mehrheitlich intakten externen Schliessmuskels. Die Effekte der
Neurostimulation auf struktureller, funktioneller und neurologischer Ebene
sind noch nicht geklärt. Daher gilt bei der Indikationsstellung auch das „trialand-error“-Prinzip. Vorteilhaft ist, dass sie ambulant und in Lokalanästhesie
durchgeführt werden kann. Zunächst wird eine Elektrode transforaminal am
Spinalnerv platziert. Objektivierbare Messungen zum Erfassen des Erfolgs
existieren nicht. Nach einer Testphase von 1-2 Wochen mit mind. 50%iger
subjektiver Besserung wird der Schrittmacher implantiert. Komplikationen
sind v.a. Infektionen, Schmerzen und Elektrodendislokationen oder –brüche.
Trotz hoher Materialkosten von 8000 Euro ist die SNS in der Schweiz seit
Anfang 2008 kassenpflichtig.
Bei ausgedehntem Verlust der Spinktermuskulatur oder kongenitalen Leiden,
z.B. Spina bifida kann eine M. gracilis-Plastik durchgeführt werden. Dabei
wird der Muskel gestielt transpositioniert, um den Analkanal geschlungen und
am Periost des Os pubis fixiert. Mit einem Schrittmacher wie bei der SNS wird
er stimuliert. Der Erfolg dieses technisch anspruchsvollen Verfahrens kann
Selim Dinçler
z.B. durch eine ungenügende Vaskularisation oder infektbedingt ausbleiben.
Der künstliche Analsphinkter ist ein mit Flüssigkeit füllbarer Silikonschlauch,
der als Manschette den Analkanal umschlingt. Das Flüssigkeitsreservoir liegt
subperitoneal, die Pumpe zur Druckregulation skrotal oder in den grossen
Schamlippen. Indikationen sind ausgedehnte Defekte, wo rekonstruktive
Verfahren oder SNS nicht weiterhelfen. Hohe Infektraten mit nachfolgender
Explantation relativieren die ansonsten guten Ergebnisse.
Bei leichten oder moderaten Formen der sphinkterbezogenen Inkontinenz
kann die Augmentation des Analkanals durch Injektion gewisser Substanzen
die Kontinenz verbessern. Neben der autologen Fettinjektion überhäuft die
Industrie den Markt förmlich mit Produkten. Stellvertretend sei hier das PTQ
erwähnt: Silikonhaltige Partikel von bis zu 450 µm Grösse werden in einer Trägersubstanz unter endosonographischer Kontrolle intersphinkter in sämtliche
Quadranten injiziert. Bei Initial deutlicher Besserung der Symptome kann die
Wirkung nach zwei bis drei Jahren nachlassen. Die Kolostomie als ultima ratio
wird v.a. bei bettlägerigen Patienten empfohlen.
Tab.1: Anamnesebezogene Gradierung der Stuhlinkontinenz nach Womack
Grad
A
B
C
D
Symptome
kontinent
inkontinent für Gas
inkontinent für Gas und flüssigen Stuhl
vollständige Inkontinenz
Tab. 2: Schematische Einteilung der Ätiologie analer Inkontinenz
1. Gewebealterung
2. sensorisch: a) Verlust sensibler Rezeptoren
b) Irritation sensibler Rezeptoren
3. muskulär (lokales, direktes Trauma)
4. neurogen: a) peripher (Plexus pudendalis und Äste)
b) proximal (spinal und Cauda-aequina – Schäden)
5. psychoorganisch
6. Reservoir-Verlust (rektale Kapazität)
7. Aufhebung des Klappenmechanismus
8. Rektumprolaps
9. Stuhlkonsistenz
10. Imperativer Stuhldrang
11. Rektozele
12. Deformierung des Analkanals (Narben)
13. kongenital
Literatur
Buchmann P. Lehrbuch der Proktologie, 4. Auflage, Verlag Hans Huber Bern 2002
Ratto R, Doglietto GB (Eds). Fecal incontinence, Springer-Verlag Italia 2007
Jane J. et al. Envolving therapy for fecal incontinence. Dis Colon Rectum 2007; 50: 19501967
Abb. 1: Behandlungsalgorithmus der Stuhlinkontinenz
Peter Buchmann
Congress Topics
Die Radiofrequenzablation erweitert das chirurgische
Therapiespektrum von Lebertumoren
Paolo Abitabile, paolo.abitabile@ksli.ch
Christoph A. Maurer, christoph.maurer@ksli.ch
Einleitung
Die Radiofrequenzablation (RFA) ist ein lokal destruierendes Verfahren, das
zunehmend an Bedeutung gewinnt. Mit entsprechender Erfahrung scheinen
Lebertumoren bis zu einem Durchmesser von 3 cm mit der RFA genauso effizient behandelbar zu sein wie mit einer chirurgischen Resektion.1,2,3
Methodik
Die Platzierung der Elektroden erfolgt mit Hilfe von Sonographie, Computertomographie (CT) oder Kernspintomographie (MR). Die applizierten Radiofrequenzen bewirken durch Gewebeerhitzung eine Zellnekrose. Das nekrotische
Lebervolumen hat dabei das Tumorvolumen allseits um rund 1 cm zu überragen.
Mulier4 konnte in seiner Metaanalyse zeigen, dass die niedrigste Lokalrezidivrate erzielt wird, wenn die RFA laparoskopisch assistiert oder über eine
Laparotomie durchgeführt wird.
Patientenselektion
Auf Grund unserer langjährigen Erfahrung mit der RFA sowie auf Grund der
aktuellen Datenlage erachten wir in folgenden Fällen eine RFA als indiziert:
1.Isolierter metastatischer Befall beider Leberlappen mit zu geringem Restlebervolumen nach Resektion.
2.Metastasenlage zentral in der Leber, welche keine R0-Resektion zulässt.
3.Tief parenchymale Lage einer Metastase < 3 cm anstelle einer extensiven
Resektion.
4.Im Rahmen von Debulking-Operationen, z.B. Ovarialkarzinom, GIST, Neuroendokrine Tumore.
5.Hepatozelluläres Karzinom bei Patienten, die auf eine Transplantation warten oder bei nicht transplantierbaren Patienten, bei denen eine Leberresektion aufgrund der Zirrhose zu riskant erscheint.
Bei Tumoren > 5 cm ist das Lokalrezidivrisiko nach RFA mit > 20% nicht
vertretbar.
Eigenes Patientengut
Seit 1998 haben wir 313 Lebertumoren anlässlich 140 Operations-Sitzungen
(100 Patienten) mit RFA behandelt. Patienten- und Tumoreigenschaften wurden prospektiv in einer Datenbank erfasst. Alle Patienten wurden konsequent
klinisch, laborchemisch (inkl. Tumormarker) und radiologisch (3-Phasen-CT,
MR in selektionierten Fällen) nachkontrolliert.
Erst kürzlich haben wir unsere Erfahrung bei 147 Metastasen kolorektalen
Ursprungs, die mit RFA behandelt wurden, publiziert.1 Eine klassische Leberresektion war in 80% der Fälle nicht durchführbar. Keiner der Patienten
verstarb in Zusammenhang mit der RFA-Behandlung. Komplikationen traten
in 7% der Fälle auf. Das mediane Überleben bei diesen Patienten betrug 39
Monate (nach Kaplan-Meier). Das kumulierte Überleben war nach 1, 2, 3, 4
und 5 Jahren 88%, 80%, 57%, 38% und 21%. Die Gesamt-Lokalrezidiv-Rate
betrug 8.8%. Metastasen < 3 cm wiesen eine Lokalrezidiv-Rate von nur 1.6%
auf. Diese Resultate basieren auf einer – im Vergleich zur Literatur – relativ
langen medianen Nachbeobachtungszeit von 33 Monaten.
Fallbeispiel
50-jährige Patientin mit Mammakarzinom. 2 Jahre nach Entfernung des Primärtumors wurde eine solitäre Lebermetastase im Segment VI nachweisbar
(Fig. 1), ohne Hinweise auf extrahepatische Metastasierung.
In dieser Situation ist eine posteriore Sektorektomie potenziell nicht kurativ,
sodass wir uns anstelle einer Hemihepatektomie rechts bei dieser Solitärmetastase < 3 cm für eine perkutane RFA entschieden.
Die post-Ablations CT-Kontrolle zeigte eine erfolgreiche Ablation mit einem
Nekroseareal, welches die Metastase allseits überragt (Fig. 2). 6 Jahre nach
RFA ist die Patientin weiterhin tumorfrei. In der letzten Kontrolle vom Oktober
2007 zeigt sich ein massiv geschrumpftes Areal im Bereich der ehemaligen
Ablationsstelle (Fig. 3).
Zusammenfassung
Die Radiofrequenzablation sollte heute zum Armamentarium eines jeden
Zentrums mit Leberchirurgie gehören. Insbesondere bei Lebertumoren < 3
cm lässt sich mit der Radiofrequenzablation in geübten Händen eine exzellente lokale Tumorkontrolle erzielen. Entsprechend ermöglicht der Einsatz der
RFA bei irresektablen Metastasen eines Kolon- oder Mammakarzinoms eine
markante Verbesserung des Überlebens im Vergleich zum natürlichen Verlauf
dieser Krankheit (best supportive care) oder alleiniger chemotherapeutischer
Behandlung.
Literatur
1. Abitabile P, Hartl U, Lange J, Maurer CA. Radiofrequency ablation permits an effective
treatment for colorectal liver metastasis. EJSO 2007; 33: 67-71
2. Gillams AR, Lees WR. Radio-frequency ablation of colorectal liver metastases in 167
patients. Eur Radiol 2004; 14: 2261-7
3. Scheele J, Altendorf-Hofmann A. Resection of colorectal liver metastases. Langenbecks Arch Surg 1999; 384: 313-27
4. Mulier S, Ni Y, Jamart J, Ruers T, Marchal G, Michel L. Local recurrence after hepatic
radiofrequency coagulation. Multivariate meta-analysis and review of contributing factors. Ann Surg 2005; 242: 158-71
Paolo Abitabile
Christoph A. Maurer
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