Swiss surgery = Schweizer Chirurgie = Chirurgie suisse = Chirurgia svizzera最新文献

Introduction: In children, the choice between percutaneous pinning (PP) and open pinning fixation (OPF) for the surgical treatment of fractures of the distal humerus remains controversial, especially the PP method for internal humeral condylar (IHC) fractures.

Patients and methods: Eighty fractures of the distal humerus in children were treated surgically in our hospital over a ten year period. 47% (n = 38) were supracondylar (SC), 20% (n = 16) comminuted (COM), 18% (n = 14) internal humeral condylar (IHC), and 15% (n = 12) lateral humeral condylar (LHC). We used PP, OPF and three times osteosynthesis with screws.

Results: In comparison to OPF, PP reduced the length of hospitalization in SC fractures (2.8 versus 6.1 days) and IHC fractures (2.4 versus five days). It reduced the risk of extension deficiency (11.1% versus 15%) and of cubitus valgus (0% versus 20%) in SC fractures, and of cubitus varus in IHC fractures (0% versus 11.1%). However it induced a higher rate of cubitus valgus (11.1% versus 20%) in IHC fractures, one persistent neurological motor deficiency (radial nerve) and four cases of transitional neurological involvement (ulnar nerve).

Conclusions: PP is a good surgical method for SC and for also for IHC fractures, if performed by experienced surgeons so as to avoid neurological damage.

Introduction: Double transplantation is one possible answer to the shortage of donor organs. While each donor kidney would be unsuitable when considered as a single allograft, use of both kidneys should provide sufficient nephron mass for effective glomerular filtration.

Case report: This is the first Swiss report of a dual adult transplant of marginal kidneys in a 46-year-old man, who was transplanted for the fourth time. Follow-up at 6 months is excellent without acute rejection.

Conclusion: Recent analysis of dual marginal versus single ideal transplant outcomes, found a comparable 1-yr graft survival in both of the procedures. Long term results are still lacking and guidelines to decide between single, double or no transplantation are emerging.

Liver transplantation is a standardized therapy for end-stage liver disease. With current immunosuppressive protocols and patient care, ten-year patient survival rate has reached 60%. Several medical complications may develop during this period, including renal dysfunction, hypertension, diabetes mellitus, hyperlipidemia, and metabolic bone disease. The aim of this article is to analyze long-term results of several clinical trials reporting common medical dysfunctions after liver transplantation and to discuss their management.

There is increasing incidence of adenocarcinoma of the esophagastric junction (EGJ) especially in young white men (+35% in 30 years). The reasons for this are not yet well known, however one of the main causes is gastro-esophageal-reflux disease (GERD). The differentiation of a EGT carcinoma in three subtypes is important for therapy: adenocarcinoma of the distal esophagus (type I), cardia carcinoma (type II) and subcardial gastric carcinoma (type III). The most important risk-factor for type I-cancers is "barrett's metaplasia" resulting from GERD over years. The risks for the type II- and type III-carcinomas may be obesity and high caloric and fat intake. The role of Helicobacter pylori infection and adenocarcinoma of the subcardia is unproven. Preoperative tumor staging is difficult and tumor-stage is most often underestimated (esp. in the case of a high-grade dysplasia where in 43% carcinomas one already established). Therapy for all three types of EGJ tumors is surgical. Transhiatal (rarely transthoracic) esophagectomy with lymphadenectomy and proximal gastrectomy is performed for type-I-tumors, type-II and III-tumors are treated like a gastric cancer with total gastrectomy, lymphadenectomy and distal esophagectomy. Lymph-node metastases and advanced tumor-stage are bad prognostic factors, complete tumor resection (R0 resection) with extended lymphadenectomy will improve prognosis. The results of a preoperative combined-modality therapy are encouraging, but have not yet shown a definitive benefit. In case of distant metastases, radio-chemotherapy combined with gastroenterologic treatments (e.g. esophageal prostheses, PEG, etc.) will be used as a palliative treatment option.

Surgery of pancreatic and biliary tract carcinomas includes an extensive surgical dissection with removal of all neural and lymphoid tissue together with a skeletonization of hepatoduodenal structures. Skeletonization or autodigestion may lead to pseudaneurysms of perihepatic arteries. Rupture of one of these aneurysms may cause a severe upper gastrointestinal bleeding. Only a few cases of these serious complications are reported in literature.

We report about the first use and successful outpatient therapy with an implantable pulsatile left ventricular assist device (LVAD, Novacor) in a patient with a combined dilative and ischemic cardiomyopathy in Switzerland. The patient, a 51 year old man (112 kg, 191 cm, blood type A) developed end-stage heart failure (New York Heart Association class (NYHA) IV) while he was awaiting orthotopic heart transplantation. Due to his profession as an independent graphic-designer the patient was afraid of a long-term temporary disablement with consecutive bankruptcy. Therefore we decided and performed the implantation of a Novacor-LVAD as a bridge to transplantation with the possibility to outpatient therapy in a favourable course. The patient was supported by the device for more than five months. His cardiac functional status returned to NYHA class I, and the patient was discharged 5 weeks after implantation. He returned into his normal life and started working at 100% again. Furthermore the LVAD enabled the patient to participate in almost all activities. Five months (151 days) after implantation a donor organ became available and the patient underwent orthotopic heart transplantation. The use and successful outpatient therapy with an implantable pulsatile left ventricular assist device in our patient has proved to be save, reliable, life-saving, quality of life improving and could be an important alternative for the economic burden in heart failure therapy.

Unlabelled: Total colonic aganglionosis (TCA) extended to the ileum is seen quite rare among infants with Hirschsprung's disease. Type and timing of definitive surgery in these patients are controversial. This report was presented to discuss the management of two siblings with TCA. Case 1: A two-day-day-old girl was operated for partial intestinal obstruction. During laparotomy, serial frozen biopsies proved TCA extended to the terminal ileum and a loop ileostomy was performed. At five months of age, a modified Duhamel-Martin procedure without protective ileostomy was performed. An endo-GIA stapler was transanally used for colo-ileal anastomosis. She is doing well for the last five years. Case 2: A one-day-old boy admitted to the hospital with similar findings to his sister. Frozen biopsies during first laparotomy proved that majority of ileum and entire colon was aganglionic and a proximal ileostomy was performed. At 10 months of age, he underwent a similar Duhamel-Martin operation. He is in a good condition for the last four years.

Conclusion: In infants, our modification on Duhamel-Martin procedure, which is based on the use of an endo-GIA stapler transanally for colo-ileal anastomosis without protective ileostomy, may be utilized as an alternative method in the definitive treatment of patients with TCA.

Anastomotic leakage after visceral surgery is one of the most important and feared complication. According to the literature the rate of clinically apparent anastomotic leakage ranges from 3.4% to as high as 12% and at least one third of the mortality after colorectal surgery is attributed to leaks at the anastomotic site. Within this context, knowledge of factors influencing anastomotic healing appears even more important. Beside surgical-technical (suture technique, suture material) and surgical-tactical factors (primary anastomosis vs. discontinuity resection or formation of protective diverting stomas) knowledge of the various endogenous (diabetes, sepsis, infection, malnutrition) and exogenous factors (steroids, radiation, preoperative bowel preparation) influencing anastomotic healing is essential. Recently, it has been demonstrated that Mycophenolate mofetil, an immunosuppressive drug that is currently used in transplantation and in chronic inflammatory diseases significantly impairs mechanical stability of the healing anastomosis. In contrary, local application of keratinocyte growth factor (KGF) as well as insulin-like growth factor-I (IGF-I) have been shown to accelerate and improve anastomotic healing and mechanical stability in an animal model. Studies that will identify further factors and drugs influencing anastomotic healing are of great importance since the use of such drugs could have enormous clinical implications. The traditional use of temporary diverting stomas following operations such as coloanal anastomosis or ileopouch anastomosis as well as Hartmann's discontinuity resection could be eliminated even in immunocompromised or other high risk patients.

With the goal of ensuring maximal safety, surgeons tend to apply antibiotic prophylaxis generously to patients undergoing selective operative procedures. However, the indiscriminate or inappropriate use of prophylactic antibiotics i) leads to the selection of resistant microbial organisms and ii) results in an increase in general medical treatment costs. Given this controversy, the clinic of reconstructive surgery implemented in 1999 a set of guidelines for the proper use of antibiotics. Antibiotic prophylaxis was defined as a pre- or perioperative application of antibiotics as a single to maximum triple-shot dose. It was recommended only for operations involving special risk factors or the implantation of alloplastic material. The recommended medication of choice was the widely-accepted standard first-generation cephalosporin product Cefazolin. We have carried out a quality control trial to analyse prospectively our own experience with the implementation of these guidelines and to compare results with a retrospective group of patients. A total of 792 patients (441 in the retrospective group, 351 in the prospective group) were enrolled in the study. About one third of all patients received an antibiotic prophylaxis. Of these, about 3/4 received the antibiotic prophylaxis without having one of the above-mentioned indications. We observed that 35% of all prophylaxis were given for breast surgery, followed by surgery for scar revisions and lipodystrophy. The most commonly used antibiotic was Cefuroxim rather than Cefazolin. There was no significant reduction in the general application of antibiotic prophylaxis yet apparent in the prospective group. However, there was a clear increase in the use of Cefazolin from 0.2% to 13.2%. We conclude that guidelines can be created to reduce the incidence of uninformed and inappropriate decisions, but their implementation requires time, motivation, and thorough and repeated information campaigns.

Background: The optimal treatment of papillary thyroid carcinoma (PTC) is still debated, also with respect to nodal treatment.

Method: Retrospective analysis of a personal series of 159 patients with PTC, with respect to nodal disease, follow up 1-27 (mean 8) years.

Results: In 42 patients with clinical, macroscopic nodal disease (cN1) a therapeutic lymphadenectomy was performed, with pN1 status in 41 (98%) patients. 117 patients had no clinical or intraoperative suspicion of nodal involvement (cN0), with occult nodal disease in 5/29 (17%) patients undergoing prophylactic (elective) lymphadenectomy, and in 2/88 (2.3%) patients without primary lymphadenectomy (metachronous nodal disease) (p < 0.005). Nodal recurrences were observed (1-5 years after primary treatment for cure) in 5/42 (12%) pN1 and in 3/114 (2.6%) cN0, pN0 tumors (p = 0.009), with unfavourable outcome in 2 and 1 patients, respectively. The 20-year tumor specific survival was 100% in TNM I + II (low risk) patients (including pN1 and N0 tumors); the survival rate was deteriorated by stage pN1 vs. N0 in TNM high risk patients (50% vs. 86%; p = 0.03).

Discussion: The intraoperative macroscopic staging (cN) remains important:--clinical nodal disease warrants a systematic node dissection (microdissection), for preventing (curable or serious) nodal recurrences. Occult nodal disease does not evolve frequently in clinical nodal recurrence. A less radical (and only central) prophylactic lymphadenectomy, avoiding surgical morbidity, may be oncologically adequate. More sensitive detection of nodal positivity (frozen section of sampling tissue or sentinel nodes, immunohistochemistry) appears not rationale. In pN0, cN0 tumors use of prophylactic 131I may represent overtreatment, and follow up controls may be conducted less rigorously.