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

The standard of care for patients with end-stage renal disease is kidney transplantation, which not only confers a survival benefit compared to hemodialysis, but is also cost-effective. The indications, contraindications as well as the preoperative assessment of recipients are discussed. The recurrence rate of the underlying renal disease has to be taken into account, especially in living donation. Growing organ shortage has lead transplant surgeons to accept older, less healthy, and even non-heart-beating donors, with generally good results. Living-donation is safe for the donor, outcome is excellent and plays an increasing role today. It has surpassed the number of cadaveric kidney transplantations in some countries. Many centres now apply laparoscopic donor nephrectomy with low morbidity. Matching for ABO blood group and HLA is routinely performed, as well as pre-transplant crossmatching. The surgical procedure has been standardized and the complication rate is low. Immunosuppressive protocols have evolved over time, and while the optimal regimen has not been defined, the availability of numerous agents allows the regimen to be individualized. New agents are being introduced into clinical practice. With increasing long-term graft survival and thus life-long immunosuppression, cardiovascular disease, de-novo malignancies and infectious complications are major causes of morbidity and mortality of transplant recipients. Effective prophylactic measures are often available, and surveillance protocols are warranted in these patients. Overall, the outcome of renal transplantation is excellent and has improved over time. Future prospects include induction of allograft tolerance, tissue engineering and xenotransplantation.

Living donor liver transplantation is a relatively new procedure in which the right side of the liver is harvested in a healthy donor and transplanted into a recipient. After the first case in 1994, over 3000 cases have been done worldwide. This review summarizes the reasons why the procedure is needed, describes its main technical aspects, highlights the boundaries in which it can be done safely, summarizes the current experience worldwide and describes the main points of the program in our unit. We argue that living-donor transplantation is a viable alternative to a long time on the waiting list for several patients, and it can be performed safely and successfully provided that all precautions are undertaken to minimize the risks in the donor and to increase the chances of a good outcome in the recipients. If these prerequisites are met, and within the framework of a structured multidisciplinary program, we believe that living-donor liver transplantation should be funded by health insurances as a recognized therapeutic option.

Background: The Sorin Pericarbon Freedom Stentless aortic valve has the potential to provide superior hemodynamic function and durability. In this study we assessed the hemodynamic performance of this valve and its impact on LV-mass regression after aortic valve replacement.

Methods: 31 consecutive patients who received a Sorin Pericarbon Freedom Stentless aortic valve were analysed. Mean age of the patients (16 female and 15 male) was 64 +/- 17 years. Five patients had isolated aortic stenosis, three isolated aortic regurgitation and one combined aortic valve disease. Three patients had combined aortic and mitral valve disease, 14 patients concomitant coronary artery disease, one congenital aortic coarctation. Three patients had an acute aortic valve endocarditis. 18 patients were classified as high-risk patients (mean EuroSCORE 9 +/- 2). Mean left ventricular ejection fraction was 52.5 +/- 15.0%.

Results: Valve sizes from 21 mm to 29 mm were implanted. The valves were oversized by 2 mm compared to measurement. 16 patients received isolated aortic valve replacement, Three patients aortic valve replacement and mitral valve reconstruction. 12 patients had concomitant CABG. Three procedures were reoperations. Hospital mortality was 6.4% (two patients). Both deaths occurred in high-risk patients and were not valve-related. Four patients had perioperative low-output-syndrome and needed IABP. After six months a follow up echocardiography was performed. Mean and peak gradients were 9.6 +/- 4.4 and 20.6 +/- 5.9 mmHg, respectively. Significant reduction of left ventricular hypertrophy (LV mass index 126.5 +/- 27.3 vs. 189.6 +/- 45.3 g/m2, p = 0.0313) and improvement of the ejection fraction (58 +/- 9.8 vs. 52.5 +/- 15.0%, p = 0.9749) as compared with preoperative valve.

Conclusions: The hemodynamic performance of the Sorin Pericarbon Freedom Stentless aortic valve is excellent and the patient outcome is satisfying. However the implantation technique requires longer ischemic time, the prosthesis offers very satisfying hemodynamic function and accelerates probably the LV-mass regression in the mid term follow-up. Late performance and durability of the valve have to be assessed.

Introduction: After introduction of the new postgraduate training program for general surgery the completion of the operation list still represents the most important step. Based on our number of operations we examined whether residents would carry out the requested interventions at our non-university teaching hospital (category A).

Method: For eight tracer operations we retrospectively counted the number of cases of the non private patients from 1998-2002 and took account of the postgraduate education status of the operator. In this period the team consisted of 51 residents (71 education years), of whom 18 candidates for general surgery who carried out the interventions (35 education years, inclusive rotation in ICU, emergency room and special surgical disciplines).

Results: Regarding all tracer operations, the amount of interventions per year and candidate which are necessary to accomplish the goal for the first four years of education are reached: appendectomy 8.9, laparoscopic cholecystectomy 7.3, open inguinal hernia repair 9.4, varicose veins operation 12.1, open colon sigmoideum resection 3.2, hip and malleolar fracture 6.9, hemithyreoidectomy 5.

Conclusion: Completion of the operation list as the major training goal was reached at our institution. Following our structured education program the demands regarding postgraduate education will be met also in future. Further studies however, must examine the impact of the new resident's work contracts dictating a reduction of the weekly working hours.

Aim of study: To investigate the short- and long-term outcome of patients with isolated lateral malleolar fracture type B treated with a single hemicerclage out of metallic wire or PDS cord.

Methods: Over an 8-year period 97 patients were treated with a single hemicerclage for lateral malleolar fracture type B and 89 were amenable to a follow-up after mean 39 months, including interview, clinical examination and X-ray controls.

Results: The median operation time was 35 minutes (range 15-85 min). X-ray controls within the first two postoperative days revealed an anatomical restoration of the upper ankle joint in all but one patient. The complication rate was 8%: hematoma (2 patients), wound infection (2), Sudeck's dystrophy (2) and deep vein thrombosis (1). Full weight-bearing was tolerated at median 6.0 weeks (range 2-26 weeks). No secondary displacement, delayed union or consecutive arthrosis of the upper ankle joint was observed. All but one patient had restored symmetric joint mobility. Ninety-seven percent of patients were satisfied or very satisfied with the outcome. Following bone healing, hemicerclage removal was necessary in 19% of osteosyntheses with metallic wire and in none with PDS cord.

Conclusion: The single hemicerclage is a novel, simple and reliable osteosynthesis technique for isolated lateral type B malleolar fractures and may be considered as an alternative to the osteosynthesis procedures currently in use.

Aim of study: In this study, we investigated the effect of the matrix metalloproteinase inhibitor batimastat on the lung colonisation of orthotopically implanted malignant pancreatic tumor cells in SCID mice.

Material and methods: Following intraperitoneal anaesthesia, 10(6) Panc-TU-1 cells were orthotopically implanted in the head of the pancreas in 20 SCID mice. Seven days later, treatment of 10 of these mice with an intraperitoneal injection of batimastat (30 mg/kg body weight) was begun and continued for 14 days. Of the mice in the untreated control group, 3 were sacrificed and examined after 7 days, a further 3 after 14 days and the remainder together with the group that had been treated after 21 days.

Results: Tumor growth was clearly visible between the 14th. and the 21st. postoperative day. The orthotopically implanted tumor cells metastasized between the 2nd. and 3rd. postoperative week in the lung. In the control group, a diffuse metastasis of the lung was observed, but in the group of treated mice no lung metastases were found.

Conclusion: In this mouse model, a clear reduction and inhibition of lung metastases from orthotopically implanted pancreatic tumor cells was achieved by treatment with the matrix metalloproteinase inhibitor batimastat.

Aims: The purpose of this study was to evaluate excision and open granulation versus excision and primary closure as treatments for pilonidal sinus.

Subjects and methods: We evaluated a group of 141 patients operated on for a pilonidal sinus between 1991 and 1995. Ninety patients were treated by excision and open granulation, 34 patients by excision and primary closure and 17 patients by incision and drainage, as a unique treatment of an infected pilonidal sinus.

Results: The first group, receiving treatment of excision and open granulation, experienced the following outcomes: average length of hospital stay, four days; average healing time; 72 days; average number of post-operative ambulatory visits, 40; average off-work delay, 38 days; and average follow-up time, 43 months. There were five recurrences (6%) in this group during the follow-up period. For the second group treated by excision and primary closure, the corresponding outcome measurements were as follows: average length of hospital stay, four days; average healing time, 23 days; primary healing failure rate, 9%; average number of post-operative ambulatory visits, 6; average off-work delay, 21 days. The average follow-up time was 34 months, and two recurrences (6%) were observed during the follow-up period. In the third group, seventeen patients benefited from an incision and drainage as unique treatment. The mean follow-up was 37 months. Five recurrences (29%) were noticed, requiring a new operation in all the cases.

Discussion and conclusion: This series of 141 patients is too limited to permit final conclusions to be drawn concerning significant advantages of one form of treatment compared to the other. Nevertheless, primary closure offers the advantages of quicker healing time, fewer post-operative visits and shorter time off work. When a primary closure can be carried out, it should be routinely considered for socioeconomical and comfort reasons.