Helvetica chirurgica acta最新文献

We performed endoluminal sonography in 23 patients with suspected inflammatory perianal or perirectal disease. In 11 patients with known fistulous disease we searched for an abscess cavity or attempted to demonstrate the track of the fistula. 8 patients were examined for perianal pain of unknown origin. In 1 patient we used the rectal sonography to define the size and precise location of an abscess. Another patient was examined for a submucous rectal tumor. Twice we used sonography for postoperative follow-up, once after incision of a dorsal horseshoe abscess and once after lateral sphincterotomy. In 19 of 23 patients (82%) with perianal inflammatory disease, endorectal sonography was either diagnostic or provided useful additional informations.

The need for a routine preoperative intravenous cholangiogram (IVC) has been controversially discussed. We decided to assess if preoperative criteria such as history, clinical examination or laboratory findings could be used for selective indication for preoperative IVC. In a series of 146 patients with a preoperative IVC before undergoing laparoscopic cholecystectomy, history, clinical findings and laboratory results (bilirubin, transaminases, alkaline phosphatase, amylase) have been correlated with the radiological findings. ERCP was taken as the standard to assess the value of IVC. A normal IVC was quite reliable in excluding any pathology of the bile ducts or common bile duct stones. Thus specificity reached 96% and the negative predictive value was 97%. On the other hand a pathological IVC proved not to be a valid predictor of true pathological alterations. Sensitivity was only 60% and the positive predictive value just 55%. Over all accuracy was quite satisfactory (94%). We could not find a correlation between history, clinical or laboratory findings and the final result as assessed by ERCP. Therefore we could not find any useful parameters to define a selective policy for indication of preoperative IVC. On the other hand the IVC still proved useful to exclude relevant pathological findings. At the time being there is no strong argument for abandoning routine preoperative IVC.

Thromboembolectomy with the Fogarty balloon-catheter is a well-established surgical therapy for the treatment of acute ischemia with generally good results. However, arterial injuries caused by balloon embolectomy occur in up to 6%. The different types of injury are mentioned, the role of myointimal hyperplasia as a result of endothelial denudation is discussed. We conclude that after balloon-catheter thromboembolectomy an early angiographic control should be performed and repeated 3 months postoperatively.

To assess the indications for routine colour flow duplex surveillance, 43 infrainguinal autogenous vein grafts were prospectively entered into a surveillance protocol. Screening consisted of measurements of ankle brachial indices (ABI) and colour flow duplex imaging of the entire graft length. All grafts at risk had a serial fall in resting ABI of more than 0.1. This study suggests that resting ABI measurements are a very sensitive and non-expensive primary screening procedure, provided that all grafts with ABI changes of more than 0.1 are further evaluated. About 60% of ABI-screened grafts needed further evaluation because of ABI changes of greater than 0.1, incompressibility of arteries or extension of the graft to the ankle or pedal arteries. Colour flow duplex scanning was very useful in excluding of identifying and localising graft problems and deciding on further invasive diagnostic and therapeutic procedures.

The double stapling technique for anterior resection of the rectum since its first description in 1980 has greatly facilitated the anastomosis of the low rectum. Few people use it also for high anastomosis of the rectum, the majority preferring hand-suture. We used this technique for 100 consecutive anterior resections of the rectum performed between August 1990 and November 1992. 51 patients had diverticulitis, 46 had carcinoma of the rectosigmoid colon, 2 had complications after pelvic irradiation and one had Crohn's disease. Surgical complications occurred in 22 patients. They include 8 patients with anastomotic leak (4 severe and 4 minor), all operated for carcinoma. Mortality was 3%. Our experience shows that this technique can be safely performed in a teaching hospital with many surgeons. It was a safe technique for high anastomosis. Surgical complication rate was higher in patients with recurrence of carcinoma and in patients previously irradiated.

Between 1984 and 1992, 79 patients were operated for occlusion of the infrarenal abdominal aorta. 12/79 (15%) of the patients underwent emergency procedure for an acute Leriche syndrome. 67/79 (85%) of the patients with a chronic occlusion were treated electively. The surgical management includes in our series in 57/79 (72%) cases aortoiliac or aortofemoral prosthetic bypass, in 11/79 (14%) cases aortoiliac endarterectomy, in 6/79 (8%) cases embolectomy and in 5/79 (6%) extraanatomical axillofemoral bypass. For chronic total occlusion of the aorta the most common procedure was prosthetic bypass in anatomical position. For emergency cases embolectomy was performed in 42%. Early morbidity rate was 26% (21/79). The most frequent complications were thromboembolic events in 7 patients, myocardial infarction in 4 patients and renal insufficiency in 4 cases. The 30-day mortality 2.5% (2/79); the cause in both cases myocardial infarction. For atherosclerotic occlusive disease of the infrarenal abdominal aorta the prosthetic bypass is the first-choice surgical procedure. For embolic occlusions and for risk patients other less burdening procedures are available.

Endorectal ultrasonography has become the preferred exam to assess the local extent of rectal cancers. From 1990 to 1992, we have examined 28 patients with a rectal cancer. The tumours were classified according to the TNM. The objective of this exam is to identify patients whose tumours have invaded the perirectal fat. These patients are first treated in our clinic by an accelerated hyperfractionated radiotherapy and then operated. The preoperative staging made with the endorectal ultrasound was then compared with the anatomopathologic staging. The depth of the invasion was assessed precisely in 78.5% of cases. The exam's sensitivity to detect the invasion of the perirectal fat was 96% and its specificity 75%. Lymph node involvement was accurately identified in 67.8% of cases with a sensitivity of 81% and a specificity of 50%. This short retrospective study confirms that endorectal ultrasonography is a highly accurate tool for the staging of rectal carcinoma prior to operation and hence to select the patients that can benefit from preoperative irradiation.

The management of severe hepatic trauma may represent a challenge in the presence of haemodynamic instability, coagulopathy, hypothermia or metabolic failure. Moreover, the choice of treatment should consider the prevention of complications. The omentum has many advantages including hemostasis, infection preventing, viability and adaptability to reconstruction as a space filler. We report the case of a 19 year-old patient who sustained a gunshot wound, involving the right elbow and forearm and the abdomen with burst of right kidney and a penetrating centro-hepatic injury (stage IV). Surgical treatment was successfully performed in two times, by gauze packing for temporary control of haemostasis and after 24 hours by omental packing to fill the dead space of hepatic lesion. The viable omentum was placed through the hepatic hole and fixed posteriorly to the skin. The postoperative period was uneventful, excluding the development of a biliary fistula which resolved after external drainage. We conclude that omental packing is a valid solution when dealing with penetrating liver injury.

In 2 1/2 years we performed at the St. Clara Hospital in Basel 954 cholecystectomies; 661 were done laparoscopically. In the laparoscopic group we observed a morbidity of 2.3%, a reoperation rate of 0.6% and a mortality of 0.15%. In the group with open cholecystectomy the morbidity was 9.9% and the mortality 1.3%. In all 954 patients who had a cholecystectomy the morbidity was 4.6%, reoperation rate 0.4% and mortality 0.5%. Because of negative patient selection a comparison with the open cholecystectomy in our series is not possible. In summary we can say that the laparoscopic procedure has a low morbidity and low mortality. With the lesser operative trauma it allows a shorter hospital stay. We believe that laparoscopic cholecystectomy with good indication will replace open cholecystectomy as the gold standard therapy of symptomatic gallstone disease.