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

The placement of an intestinal stoma is still a common procedure despite the recent advantages in intestinal surgery. It is mandatory to apply meticulously sound surgical principles in order to achieve good results. Nevertheless, intestinal stomas are envisioned with a high perioperative morbidity which is mostly caused by surgical inadequacy. This can lead to considerable problems in management of the stoma in the long term and ultimately will affect quality of life of the patient. The cumulative morbidity can be given by 50% with prolaps, hernia, stenosis and necrosis as well as stoma retraction being the most relevant. In contrast, an adequate intestinal stoma will positively affect the quality of life of the patient. The availability of devices developed by the industry and the inauguration of a professional service in certain hospitals simplified the management of patients with a stoma. This significantly improved the standards of care especially regarding preoperative preparation and postoperative management. Thus, most patients are able to maintain an active and socially integrated life with minimal physical and psychical limitations.

Aims: The aim of this study was the evaluation of early results of esophageal resection for cancer including the assessment of pre-operative risk factors and post-operative mortality (risk score developed by Barthels et al. 1998).

Methods: One hundred and eighty one patients with esophageal cancer were operated with curative intention between October 1993 and December 2002. In a prospective analysis were reviewed: patient characteristics, characteristics of the esophageal cancer, part and type of esophageal resection, radicality, complications and mortality.

Conclusion: In total, a resection of the tumor could be achieved in 143 cases (79.0%). The overall complication rate was 52.5%, mainly cardio-pulmonary complications (25.9%) were seen. The surgical complications were determined by anastomotic leak (12.6%) and recurrent nerve injury (9.1%). Both types of complications were observed significantly more often after esophageal resection with a cervical anastomosis (p = 0.03 and p < 0.01). The hospital mortality was 8.4%. The 30 days mortality was 4.9%. Using a preoperative risk score retro- and prospectively, our data showed a lower mortality in patients with a low risk profile (2.4% and 2.3%) compared to those with a medium risk profile (7.4% and 6.4%). The only patient with a high risk profile died after resection.

Discussion and summary: The results of this analysis show that resection of esophageal cancer can be accomplished with acceptable morbidity and mortality. However, it has to be taken into account that the increase of pre-operative factors leads to an increase in post-operative mortality.

Isolated agenesis of the gallbladder (AG) is a rare anomaly. Twenty-three percent of the patients are symptomatic and present with right upper abdominal pain, nausea and fatty food intolerance. The condition is frequently mistaken with excluded or sclero-atrophic gallbladder, regardless of the imaging modality used. Consequently, AG leads often to unnecessary and potentially dangerous surgery. During laparoscopy, the absence of normal anatomical structures and the impossibility of pulling on the gallbladder to dissect the triangle of Callot represent an increased risk of iatrogenic injury to biliary or portal structures. The aim of this study is to discuss the pitfalls of the available radiological exams and the management of this rare condition. We describe two cases of AG, with a review of the literature. A high index of suspicion is necessary when interpreting the radiological images. In case of doubt, a MRI-cholangiography is mandatory. Because of possible inherited transmission, relatives with a history of biliary symptoms should be investigated, even when asymptomatic.

Mesothelioma are primary malignant neoplasms of the serous membranes. They usually involve the pleura and rarely the pericardium, the peritoneum and the tunica vaginalis testis. About 90% are associated with exposure to asbestos. The exposure is generally occupational, an environmental inhalation of asbestos and asbestiform fibers in areas in Turkey has been observed and presents a major health problem. This report of a patient from Anatolia with peritoneal mesothelioma after environmental exposure outlines the importance of considering this pathology in the differential diagnosis of a Turkish patient presenting with ascites.

Purpose: Minimally invasive repair of pectus excavatum (MIRPE) was first reported in 1998 by D. Nuss. This technique has gained wide acceptance during the last 4-5 years. In the meantime, some modifications of the technique have been introduced by different authors. Our retrospective study reports our own experience over the last 36 months and modifications introduced due to a number of complications.

Methods: From 3/2000 to 3/2003, 22 patients underwent MIRPE. Patients median age was 15.5 years (10.7 to 20.3 years). Standardised preoperative evaluation included 3D computerised tomography (CT) scan, pulmonary function tests, cardiac evaluation with electrocardiogram and echocardiography, and photo documentation. Indications for operation included at least two of the following: Haller CT index > 3.2, restrictive lung disease, cardiac compression, progression of the deformity and severe psychological alterations.

Results: In 22 patients (2 girls, 20 boys) undergoing MIRPE procedure, a single bar was used in 21 patients and two bars in one boy. Lateral stabilisers were fixed with non resorbable sutures on both sides. Overall, postoperative complications occurred in six patients (27.3%). In two patients (9.1%) a redo-procedure was necessary due to bar displacement. An additional median skin incision was performed in two patients to elevate the sternum. Pneumothorax or hematothorax in two patients resulted in routine use of a chest tube on both sides. Long-term favourable results were noted in all patients.

Conclusions: The MIRPE procedure is an effective method with elegant cosmetic results. Modifications of the original method help to decrease the complication rate and to accelerate acquirement of expertise.

Since 1983, lung transplantation has enjoyed increasing success and has become the mainstay of therapy for most end-stage lung diseases. While the first decade of clinical lung transplantation focused on technical details of the transplant procedure, the second decade was characterized by improvements in techniques of lung preservation and in the postoperative management. This review will focus on the recent improvements made in lung preservation and postoperative management.

The intramedullary Kirschner wire fixation of distal metacarpal fractures reported by Foucher et al. combines the known advantages of intramedullary implants with a reduction of iatrogenic soft tissue trauma. We applied this minimal invasive internal fixation technique in 38 patients with fractures dislocated by more than 20 degrees and/or with rotatory deformity. After opening the intramedullary cavity from the base of the respective metacarpal bone and after fracture reduction, two pre-bent Kirschner wires were intramedullary inserted in an orthograde fashion. The pre-bent distal end of the wire in the form of a hockey club allows an additional closed reduction of the displaced distal fracture fragment. Intraoperative complications did not occur. A fixation in a plaster splint followed for one week only. The elastic fixation of the wires working as springs is stable enough to allow physiotherapeutic exercises. After the third postoperative week, the intensity of physical exercise was increased. 36 of the 38 patients were followed. With one exception, all fractures were healed in a proper position. The wires were removed under local anaesthesia on an outpatient basis after six to eight weeks and full mobility of the fingers was achieved in 34 patients at that time. Complications included one redislocation and one distal wire perforation.

There is an ongoing discussion in surgery about what is the best or "correct" technique for gastrointestinal anastomosis. An ideal anastomosis should fulfill the following criteria: it must be well vascularised, safe ("waterproof"), easily feasible, tension-free, spillage should be avoided and it should be inexpensive. We give an illustrated report of the surgical technique of the continuous single-layer anastomosis in the gastrointestinal tract. On the basis of a pilot study, a randomised comparative study, a Swiss multicenter trial and, finally, a prospective 5-year-follow-up quality control study we demonstrate that this "Schweizer (Swiss)"-technique fulfills the criteria of an "ideal" anastomosis and can be used in almost all intestinal localisations.

The first-line therapy for inflammatory bowel disease flares is typically medical in nature. Glucocorticoids are a mainstay for the treatment of severe inflammatory bowel disease. Aminosalicylates are efficacious in the treatment of active mild- to- moderate disease. Infliximab, a chimeric monoclonal anti-TNF alpha antibody can be used in refractory Crohn's disease. The recurrence rate after surgery or medical therapy is high. Therefore the introduction of a maintenance therapy is important in patients with repetitive flares. In patients with ulcerative colitis aminosalicylates are useful as maintenance therapy. In severe ulcerative colitis or in Crohn's disease immune suppressive strategies such as a therapy with azathioprine, 6-mercaptopurine or methotrexate should be considered. In Crohn's patients with fistula surgical treatment or a therapy with antibiotics, immunosuppressants or infliximab is recommended.

The central hypothesis explored in this paper is that colorectal cancer (CRC) is a heterogeneous disease. The initial clue to this heterogeneity was provided by genetic findings; however, embryological and physiological data had previously been gathered, showing that proximal (in relation to the splenic flexure) and distal parts of the colon represent distinct entities. Molecular biologists have identified two distinct pathways, microsatellite instability (MSI) and chromosomal instability (CIN), which are involved in CRC progression. In summary, there may be not one, but two colons and two types of colorectal carcinogenesis, with distinct clinical outcome. The implications for the clinicians are two-folds; 1) tumors originating from the proximal colon have a better prognosis due to a high percentage of MSI-positive lesions; and 2) location of the neoplasm in reference to the splenic flexure should be documented before group stratification in future trials of adjuvant chemotherapy in patients with stage II and III colon cancer.