European Surgery-Acta Chirurgica Austriaca最新文献

Summary: Background: Sentinel lymph node biopsy seems to be a promising new method for determining axillary status in breast cancer. The method helps to reduce morbidity, and an increased number of micrometastases are detected in the sentinel nodes by which patients with a less favourable outcome are identified. However, no long-term follow-up data is available. Methods: Data from 1567 breast cancer patients treated at nine institutions in Austria were collected in a centrally reviewed database. Included in this study were 383 patients with a negative sentinel node biopsy who were treated without axillary dissection. The median follow-up was 19.5 months. Results: Sentinel node biopsy was performed using blue dye (21.2 %), radiocolloid (24 %) or the combination of both methods (54.8 %).Two axillary recurrences were observed. Both patients developed distant disease synchronously or metachronously. Primary tumours of both patients showed high nuclear grading and negative hormone receptor status. Tumour size at primary diagnosis was 12 mm and 22 mm, respectively. Conclusions: The current results of sentinel node biopsy seem to confirm the accuracy of the method. There are only sporadic reports in the literature on axillary recurrence after sentinel node biopsy. The risk of treatment failure after sentinel node biopsy can only be determined after the completion of prospective randomized trials. Therefore, sentinel node biopsy should be performed within therapeutic concepts with quality control.

Summary: Background: Current applications of robotics include surgical assistance, dexterity enhancement and image-guided therapy. Our study reports on a series of minimally invasive tubal reanastomoses performed using robotics, evaluating their feasibility and safety.Methods: Tubal surgery using the da Vinci™ surgical system was performed on consecutive patients, who requested restoration of fertility after tubal sterilisation.Results: A total of 8 tubes in five patients were anastomosed and patency confirmed; mean total operating time was 189 ± 41 minutes. Hystero-contrast-sonography after 6 weeks demonstrated patency in 7 of the 8 fallopian tubes anastomosed. There have been two pregnancies after a mean follow-up time of 5 months.Conclusions: This initial study documents the feasibility of robotically assisted surgery in gynaecology, tubal reanastomosis being the main indication. For the moment, however, in gynaecologic surgery, there are limited indications for its widespread use.

Summary: Background: Robotics in urology is a recent innovation. They offer some attractive features in laparoscopy. All six degrees of freedom are restored at the instrument's tip and a three-dimensional view is available. Remote-controlled surgery is possible using the new robotics. We investigated the applicability of remote-controlled robotics to different laparoscopic procedures in urology.Methods: In a first step, we adapted reconstructive procedures such as pyeloplasties and nephropexy, which were already being performed by laparoscopy at our institution, to robotic surgery. In a second step, we performed ileocystoplasties using the robot, which until this time had always be done by open surgery.Results: The nephropexy as well as the 11 pyeloplasties could be finished as planned with the robot. Dissection was more time consuming with the robot than with conventional laparoscopy, whereas the reconstructive part was much faster compared to conventional laparoscopy. One of the ileocystoplasties had to be converted; the second one was finished as planned.Conclusions: Robotic surgery also facilitates difficult reconstructive procedures by enhancing surgical dexterity, but development of more and different kinds of instruments is still necessary.

Summary: Background: Postoperative complaints after total knee arthroplasty range from restriction in range of motion, recurrent swelling, and soft tissue impingement through to prosthesis failure with no obvious radiological abnormality. This study looks at the indications and technical problems of arthroscopy in the treatment of symptomatic total knee arthroplasty. Methods: Fourteen arthroscopies were performed between 3 days and 10 years following total knee arthroplasty. Six of these cases presented significantly decreased range of motion, four had proximal medial joint line pain, two had pain with no obvious cause, one had a suspected patella incongruence with metal-back contact, and one case had a postoperative haemarthrosis. Results: Arthroscopy revealed adhesions and intra-articular fibrous bands resulting in incongruence of the patellofemoral joint and decreased range of motion. Medial compartment pain was due to pseudomeniscal hypertrophic villous synovium. In one case, the pain was due to chronic infection and open synovectomy was undertaken. A fracture of the polyethylene inlet was found by arthroscopy in one case. The suspected patella malalignment with metal-back contact was confirmed by arthroscopy. Technical problems encompassed mirror images, the possibility of damaging the components by arthroscopic manipulation, and the variants of prosthesis. Conclusions: Arthroscopy of total knee arthroplasties is a good minimally invasive method for the diagnosis and treatment of postoperative dysfunction, such as arthrofibrosis, soft tissue impingement, patella instability, infection, breakdown of implants and haemarthrosis.

Summary: Background: Bilateral multinodular goitre is a manifestation of unspecific proliferation of thyroid tissue often accompanied by multiple cold nodules scintigraphically. The suspicion of thyroid cancer cannot be completely excluded by the patient's history, physical examination, ultrasonography, fine needle aspiration cytology, or intraoperative frozen section. To evaluate surgically related morbidity and the incidence of occult thyroid cancer in multinodular goitres, the technique of bilateral en bloc resection has been analysed.Methods: From January 1995 to December 1998, 771 operations for benign goitre disease were evaluated in a prospective study. A primary bilateral en bloc resection for multinodular goitre was performed in 306 consecutive patients (39.7 %). Results were compared with the multicentre German Quality Assurance Study for Benign and Malignant Goitre (GQASG) in 1998.Results: Mean weight of resected specimens was 105.3 g, and mean thyroid remnant volume was 2.4 ml. The postoperative rate of transient and permanent recurrent laryngeal nerve (RLN) palsy for nerves at risk was 2.1 % and 0.8 %, respectively. There was no statistically significant difference for RLN palsy between en bloc resection and conventional bilateral resection of the control group. Transient and permanent calcium supplementation was required in 7.5 % and 3.6 %. Thyroid cancers were diagnosed histopathologically in 10 patients (3.6 %). A completion thyroidectomy was required in three patients (1.0 %) due to incidental follicular thyroid carcinoma.Conclusions: Bilateral en bloc resection of the thyroid represents an alternative technique with no increased morbidity compared to conventional resection and facilitates the application of surgical oncological principles in the case of occult thyroid malignancy.

Summary: Background: There have been an increasing number of articles regarding patients with familial non medullary thyroid cancer (FNMTC) in the past few years. FNMTC has been defined as families with two or more first degree relatives having papillary or Hurthle cell thyroid cancer.Methods: The history and new aspects of genetics, environment, pathology, management and clinical outcome of FNMTC are reviewed.Results: The familial occurrence of NFMTC was first noted in 1995. In families with three or more members with NFMTC there appears to be an autosomal dominant type of inheritance with incomplete penetrance. 99.9 % of these patients have familial disease. FNMTC without any other associated syndrome accounts for about 5 % of patients with thyroid cancer of follicular cell origin (prevalence ranges between 3.5 and 6.2 %). When two members of a family have thyroid cancer about 50 % will have a susceptibility gene for thyroid cancer. FNMTC is rare in patients with follicular thyroid cancer. To date, genetic testing to document whether an individual of a family with familial papillary or Hurthle cell cancer without other syndromes has a specific germ line mutation is not available. In 1998 a linkage site locus (thyroid cancer oxyophilia – TCO gene) on chromosome 19p13.2 in a single French family with oxyophilia and trabecular thyroid cancers was identified. Individuals with the TCO linkage site have a relatively characteristic histologic pattern with trabecular and oncocytic neoplasms. Patients with papillary thyroid cancers and familial polyposis also have a distinct architecture and primarily occur in women. An experienced pathologist can make or at least suggest that the patient with this particular histological pattern should be screened for FNMTC. When total thyroidectomy with removal of regional lymphadenopathy can be done safely this is the preferred approach for patients with nodules in families with FNMTC as recommended for patients with thyroid nodules and a history of radiation exposure. For individuals in families with two or more other members with papillary or Hurthle cell thyroid cancer and a normal thyroid gland to palpation a baseline ultrasound examination is recommended, to document whether there are any thyroid nodules present. If occult nodules are present they can be observed with a repeat ultrasound examination in six months and then yearly to be sure they are not growing, or they can be biopsied by FNA under ultrasound guidance. Although occult thyroid cancers are usually of little clinical significance this may not be true for patients with FNMTC. Occult thyroid cancers in patients with FNMTC seem more aggressive and may be lethal.Conclusions: Several groups continue to try to identify the genes responsible for the majority of families with FNMTC. Such studies are relatively expensive, but seem necessary to improve the care of patients with FNMTC.

Summary: Background: Laparoscopic surgery offers distinct benefits to patients but places a burden on surgeons regarding manoeuvrability of instruments and visualization of the operating field. The introduction of robotic telemanipulation systems offers a solution to these problems in videoscopic surgery.Methods: In this study, the feasibility of robot-assisted laparoscopic surgery was assessed by performing 40 laparoscopic cholecystectomies with the da Vinci™ robotic system. Time necessary for system set-up and operation was recorded, as well as complications, technical problems, postoperative hospital stay, morbidity and mortality.Results: 39/40 procedures were completed laparoscopically with the da Vinci™ system. There were no intraoperative complications and only minor technical problems. Median hospitalization was 2 days. System set-up time decreased with increasing experience of the operating team. Operating time was at least comparable to times reported for standard laparoscopic cholecystectomy in the literature. There was neither postoperative mortality nor morbidity at the time of discharge and during short-term follow-up.Conclusions: Robot-assisted surgery was repeatedly proven as a safe and feasible approach to laparoscopic cholecystectomy.

Summary: Background: In breast cancer patients the axillary nodes play an important role because of their predictive potential. But the merits of routine diagnostic axillary dissection have increasingly been questioned in the past few years on account of the resultant postoperative morbidity. Rediscovered and reinstated in the early 1980s, sentinel node biopsy (SNB) raised new hopes for differential staging with minimal morbidity. Methods: Based on a review of the available literature, the current role of sentinel node biopsy and its future perspectives are discussed and critically evaluated. Results: Sentinel node biopsy proved to be a practicable procedure for precise nodal staging in breast cancer patients associated with low postoperative morbidity. Serial sections of the sentinel node and immunohistochemical assays provide detailed information on lymphatic drainage and more precise staging information. As a by-product, sentinel node biopsy has re-opened the debate about the importance of micrometastases. Clearly defined criteria for patient selection, interdisciplinary cooperation, careful documentation and follow-up are the keys to its success. Conclusions: Like breast-salvaging surgery, sentinel node biopsy appears to mark a major advance in the management of breast cancer patients. More insights into the significance of micrometastases and the role of axillary dissection as well as into the usefulness of SNB post-preoperative chemotherapy and in multicentric lesions can be expected.

Summary: Background: In the past 15 years, abdominal and thoracic surgery has been greatly changed by the introduction of minimally invasive techniques; these offer great advantages for the patient but pose problems for surgeons. Disadvantages due to the limited movement radius of the endoscopic instruments and the rigidity of the instrument tips can be reduced or eliminated by the use of computer-assisted telemanipulators.Methods: We report our experience with eight abdominal and seven heart operations performed between 16 March and 31 July 2001 with a Zeus™ surgical robotic system. There were four cholecystectomies, four Nissen fundoplications, five atraumatic dissections of the left internal mammary artery (ITA), and two pericardotomies.Results: All but one operation were completed successfully with the Zeus™ device. No patient suffered any peri- or postoperative complications. Due to an electronic defect in one of the manipulators, the final cholecystectomy had to be completed as a conventional laparoscopic procedure. The duration of surgery was about 40 % longer than with conventional laparoscopic technique. The specific costs related to the robotic system were EUR 910 per operation.Conclusions: Computer-assisted manipulators are at a developmental stage that allows their successful use in clinical applications. Routine use is, however, at present only possible with a limited number of procedures.