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

Background: There is accumulating evidence, both quantitative and qualitative, that pelvic irradiation affects anorectal function. However, the molecular mechanisms responsible for radiation-induced damage to the anal sphincter remain unclear.

Aim: To determine the expression of transforming growth factor-beta 1 (TGF-beta 1) and its downstream effector connective tissue growth factor (CTGF) in the anal sphincter of a patient irradiated for prostate cancer.

Patient: A 82 year-old patient developed a rectal adenocarcinoma and underwent an abdomino-perineal resection (APR), four years after receiving pelvic irradiation for prostate carcinoma.

Methods: Tissue sections of the anal sphincter were processed for histology. Immunostaining for TGF-beta 1 and CTGF were performed.

Results: CTGF and TGF-beta 1 immunoreactivity was detected in the irradiated anal sphincter, and was absent in controls. Immunoreactivity for both cytokines predominated in the internal sphincter. CTGF and TGF-beta 1 were preferentially detected in endothelial cells, myofibroblasts and fibroblasts; in addition, there was strong immunoreactivity for TGF-beta 1, but not for CTGF in smooth muscle cells of the anal canal.

Conclusion: Four years after pelvic irradiation, radiation-induced damage appeared to affect predominantly the smooth muscle layer of the anal canal. The molecular mechanisms responsible for radiation-induced fibrosis to these tissues involve prolonged activation of TGF-beta 1 and its downstream effector CTGF.

Postoperative morbidity after pancreatic resection is primarily due to leakage of the pancreatic anastomosis. The duct-to-mucosa pancreatico-jejunostomy either as an end-to-end or end-to-side anastomosis is the preferred technique in our hands. The use of a temporarily catheter to drain the main pancreatic duct is optimal. The pancreatic leakage rate depends in many series on the consistence of the pancreatic parenchyma, the diameter of the major pancreatic duct and the local perfusion. A meticulous, standardized technique, the possibility to adapt the technique in case of unexpected findings and the operative routine of the surgeon are of paramount importance for achieving a low leakage rate. In so called "high volume" centers the pancreatic fistula rate today is in the range of 3 to 13% and the mortality of pancreatic head resection varies between 0.5 and 3%.

Since the availability of ciclosporine, the survival after heart transplantation has dramatically improved. We present our results since the beginning of our experience in 1987. We treated in the Lausanne University hospital, 150 patients for end-stage cardiac disease. Hundred and fifty-two transplantations were performed. The survival rate is comparable to the literature with 81% at one year, 70% at five year and 63 at ten year included the hospital mortality. We review the incidence of complications during the follow-up and report the modification in the management of these patients especially concerning the immunosuppression.

Thrombophlebitis is a common condition which can lead to deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE). Thrombophlebitis can reach the deep venous system via the long or short saphenous vein or via perforating veins. Between the 1st of January 1999 and the 31st of December 2000 a total of 17 cases of superficial (or ascending) thrombophlebitis closer than 5 cm to the deep venous system were surgically treated in our clinic. 14 times the long saphenous vein was affected and 3 times the short-saphenous vein. The age of the nine females and seven males ranged from 31 to 77 (mean of 54.6) years. Duplex ultrasound was performed in all patients. In the case of a deep venous thrombosis (four cases) a computer tomography scan (CT) of the pelvis and abdomen was performed to define the extension of DVT. In all 17 (100%) cases a high ligation (crossectomy) and in four (23.5%) cases a venous thrombectomy was performed. In all of these four cases the DVT was limited to the common femoral vein. In all seventeen procedures including venous thrombectomy there was no mortality and no relevant morbidity. Mean hospitalization time was 3.1 days for crossectomy with thrombectomy, and 1.8 days for crossectomy alone. Follow-up has been so far uneventful (mean follow-up time being 12 months in the case of a DVT). In the literature there is no clear concept of how to treat, conservatively or operatively, ascending thrombophlebitis. The surgical procedure can be performed under local anesthesia, and it is safe and efficient.

Description of the most important steps in the evolution of intestinal suture technique: The simple Lembert suture and its precursors, the two-layer suture, and the adapting one-layer suture. The contributions of Ph. F. Ramdohr. Wolfenbüttel, 1727, A. Lembert, Paris, 1826, F. Wydler, Aarau, 1865, and Th. Kocher, Bern, 1878-1907, are presented in more details.

Islet of Langerhans transplantation is gaining recognition as a therapy for type 1 diabetes. The procedure involves enzymatic digestion of the pancreatic tissue, purification of the islets from the exocrine tissue, infusion of the islets into the portal vein and implantation in the liver. Until 1999, and overall rate of insulin independence of 14% at one year was reported in the International Islet Transplant Registry. The results of the "Edmonton protocol" since 2000 were a breakthrough in the field, with reports of 80% insulin independence at 1-year after solitary islet transplantation in non uremic patients with brittle type 1 diabetes. A rapamycin-based, steroid-free, islet-sparing immunosuppressive regimen was designed and the problem of the insufficient islet mass was tackled by sequential infusions of islets isolated from at least two pancreatic. The University of Geneva has been involved in clinical islet transplantation since 1992, and has performed 51 allogeneic and 17 autologous. Twenty-one patients have been transplanted in Geneva since 2002. They were five solitary islet transplants, 14 islet after kidney transplants and two simultaneous islet-kidney (SIK) recipients. Insulin independence was achieved in 67%.

Unlabelled: The rate of unnecessary appendectomy is frequently criticized. Today, sonography and CT-scan are helpful tools to minimize this rate. Which value has the ultrasonography in the decision making today?

Methods: Retrospective analysis of 132 patients undergoing appendectomy in respect of sonography and rate of histologically confirmed appendicitis from 1.1.95-31.12.98. Prospective analysis of 99 patients admitted for acute appendicitis in respect of pre- and posttest-probability (after sonography) by the responsible surgeon from 1.1.99-31.12.00.

Results: Retrospective part: 122/132 patients had an acute appendicitis (92%). Sonography was performed in 64% of the patients. There was only one wrongly positive sonography. Prospective part: 76/99 patients were operated on. 70/76 had an acute appendicitis (92%). Sonography was performed in 87%. Six patients presented a histologically normal appendix: In two of them no increase of the probability after sonography was noted, in three of them an slight increase of only 20%, and in one of them a decrease of 20% even.

Conclusion: Sonography with a pre- and posttest-probability is recommended in clinically doubtful cases. In our experience the physician performing the sonography is almost always right. But the diagnosis of an acute appendicitis remains a combination of clinical and sonographic evaluation.

Who ever is writing about standards should put himself the question: What is a standard? How is it produced? Who is defining it? How compulsory is it? A standard should only be understood as guiding principles or as following guidelines and never as a dogma, while otherwise every operative technical or therapeutical progress is prohibited. On the basis of the onco-surgical guidelines for the colo-rectal carcinoma is shown how standards can begin to sway. The Turnbull "no-touch isolation technique" does not stand up to the criteria of the evidence based medicine. The usefulness of the high ligation of the veins and the intestinal occlusion has not been proven by any studies. The central ligature of the Arteria mesenterica inferior in left resection is wrong according more recent anatomical knowledge. Ligation near to the aorta leads obligatory to lesions of the plexus hypogastricus. Animal experiments are controversial concerning the dissemination of tumour cells during crushing of the cancer. And a prospective controlled study does not show any advantage of respecting the Turnbull criteria. Independent prognostic factors are the surgeon, the frequency of performing the procedure in the hospital concerned, the pT and N stage, the R-0 resection and according to American pathologists the pre-operative CEA titre. Also are mentioned the infiltration of veins and lymph vessels, micro metastases in lymph nodes and the grading. The resection should if possible be performed in anatomical layers, specially considering the meso-rectum. What should be done in the distal 8 cm till the pelvic floor has not yet been clarified. On the contrary, the laparoscopic surgery has definitively also found its acceptance in oncological surgery. The discussions about port-metastases and tumour-cell-dissemination by the pneumoperitoneum-gas have silenced. Already, partially better long-term results are mentioned. In the beginning of 2003, the pillars of the standard technique of oncological colo-rectal surgery are besides the orthograde intestinal flushing, the pre-operative low molecular Heparin and the antibiotic prophylaxis, the open or laparoscopic R-0 en bloc resection, the minimal safety distance in the low rectum of 1 cm, the ligature of the Arteria mesenterica inferior 2-3 cm distally to its origin from the aorta in case of left resection, respectively the Arteria ilio-colica at its origin from the Arteria mesenterica superior in case of right resection, the cytotoxic intestinal flushing in case of left resection and the flushing of the abdominal cavity as well as the port-site with Taurolin 0.5%. In case of rectum-carcinoma uT3 or uN+, a neo-adjuvant radio-chemotherapy is administered and adjuvant chemotherapy is given by positive nodal colon-carcinoma.

Following conservative treatment of acute colonic diverticulitis at least one fourth of the patients experiences a further attack. The complication rate rises up to 60% at the recurrence. Therefore, colon resection is indicated at/following the second attack. For male patients below 50 years of age and with severe first attack, surgery is recommended already at/following the first attack. In the absence of diffuse fecal peritonitis, the one-stage colon resection with primary anastomosis is widely accepted, now. Percutaneous drainage of a peridiverticular or paracolic abscess is hazardous (success rate 70%), dangerous (consecutively delayed elimination of septic focus, 5% complication rate of drainage itself) and not necessary or helpful. Recurrent diverticulitis following sigmoid resection rarely occurs (1-11%) and is avoidable by removal of at least 20 cm colon including the rectosigmoid junction and anastomosis to the rectum. An extension of the resection towards cephalad direction to remove as much diverticula as possible seems not to decrease the risk of recurrent disease and is therefore not worthwhile.