Anti-infectious prophylaxis after splenectomy: current practice in an eastern region of Switzerland.

Overwhelming post-splenectomy infection (OPSI) is a long-term risk in asplenic patients, which may be minimised by appropriate preventive measures. In this survey anti-infectious strategies after splenectomy were evaluated in an eastern part of Switzerland. We found 91 individuals in the canton of Thurgau, who underwent splenectomy between 1998 and 2003. We assessed adherence to vaccination guidelines, the use of antibiotics and the awareness of the infectious risks by review of hospital charts and by structured interviews with patients and their general practitioners. The total vaccination rate was 64/91 (70%). 6 patients were vaccinated pre-operatively, 50 during the hospital stay and 8 after discharge by the general practitioner. 64 received vaccination against pneumococci, 6 against haemophilus influenzae and 3 against meningococci. Although 39 died during the study period, none died of overwhelming sepsis. None of the patients received a booster vaccination. Prophylactic long-term antibiotics were given to 2 children but to none of the 89 adults. Three adults had a supply of stand-by antibiotics at home. Less than half of the patients who were interviewed knew that asplenia puts them at greater risk for life-threatening infections and few practitioners were aware that travel and animal bites pose a special threat. We conclude that after splenectomy vaccination discipline and patient education should be substantially improved and suggest the publication of comprehensive guidelines.

The effect of dopamine on hepatic-splanchnic blood flow after open heart surgery.

Dopamine (3,4 dihydroxyphenylethylamine) increases cardiac output and in particular the renal blood flow at the expense of other regional vascular beds not yet defined. Since the results of dopamine-induced changes in splanchnic perfusion are inconsistent, the effect of 6 mcg/kg/min dopamine was studied in 9 patients early after open heart surgery. Estimated hepatic blood flow (EHBF) was calculated from the concentration-time slopes of Indocyanine Green (ICG, Cardiogreen) in arterial and hepatic venous blood following single intravenous injection. Blood volume was measured using 51Cr tagged red cells. Cardiac output was determined according to the Fick method. 6 mcg/kg/min dopamine caused a mean EHBF-increase of 82%, from 492 +/- 64 to 824 +/- 80 ml/min/m2 (P less than 0.001). Related to the corresponding increase in cardiac index (CI) from 2.6 +/- 0.2 to 3.8 +/- 0.3 1/min/m2 (P less than 0.001), the EHBF/CI-ratio changed from 18.5 to 21.7% (P less than 0.025). The arterial-hepatic venous oxygen difference was reduced from 7.40 +/- 0.53 to 4.91 +/- 0.60 Vol% (P less than 0.001). It was concluded that splanchnic perfusion does not contribute to the preferential increase of renal blood flow under dopamine under the above mentioned conditions. Dopamine had the most beneficial effect on EHBF in two cases where the latter was severely reduced.

Laparoscopic sonography. An alternative to routine intraoperative cholangiography?

OBJECTIVE: To determine whether laparoscopic sonography (LS) could be a valid alternative to intraoperative cholangiography (IOC) in the detection of bile duct stones and anatomical variations. DESIGN: Prospective, controlled study comparing LS and IOC using intraoperative findings and/or postoperative endoscopic retrograde cholangiopancreatography as the gold standard. SETTING: Department of Surgery at Zürich University Hospital, Switzerland. PATIENTS: One hundred consecutive patients undergoing laparoscopic cholecystectomy between January 1992 and January 1993. Twenty-three patients were operated on for acute cholecystitis, while the remainder experienced symptomatic bile duct stones. Ninety-six patients underwent preoperative sonography and 85 underwent intravenous cholangiography. Laparoscopic sonography was performed in all patients after dissection of the cystic duct. INTERVENTIONS: A 5.5-MHz sector scanner with a 360 degrees angle and an optimal depth of 1 to 4 cm was used. After LS, IOC was performed with a 4F ureteric catheter and a modern fluoroscope. Patients with bile duct stones were sent for endoscopic retrograde cholangiopancreatography postoperatively or the stones were removed laparoscopically. RESULTS: Unsuspected common duct stones in three patients and several small calculi in the cystic duct in one patient were detected intraoperatively. Sensitivities and specificities for the detection of bile duct calculi were 100% and 98% by LS and 75% and 99% by IOC, respectively. Anatomical variations of the extrahepatic bile ducts were detected by LS in 20 patients and by IOC in 21 patients. Laparoscopic sonography visualized variations of the hepatic arteries in 22 patients. The average time consumption for LS was 5.4 minutes (range, 2 to 12 minutes) and 16.4 minutes for IOC (range, 4 to 37 minutes). CONCLUSIONS: Laparoscopic sonography is a quick and reliable intraoperative diagnostic tool and could replace IOC in laparoscopic cholecystectomy. Additional trials in a larger patient population are needed for a final assessment.

The ascending aortic aneurysm: replacement or repair?

Between 1971 and 1980, 100 patients underwent operation for ascending aortic aneurysm. Acute dissection was present in 29, chronic dissection in 11; 56 had dilatation only, and 4 had inflammatory disease of the ascending aorta. Four different operative procedures were applied independent of the type of disease: repair and reduction aortoplasty (21), reduction aortoplasty reinforced by nylon net (17), supracoronary graft replacement (42), and composite graft replacement with reimplantation of both coronary ostia (20). Early mortality was 10%, and late mortality was 12% after a mean follow-up of 45 months. Retrospective comparative analysis of the four operative methods led to the following conclusion: reduction aortoplasty supported by a tightly wrapped synthetic net is a suitable method in patients with a normal sinus of Valsalva and without dissection or inflammatory disease. Particular attention needs to be drawn to the proximal anchor stitches to avoid late net displacement. Compared with supracoronary or composite graft replacement, this method carried a lower complication rate, particularly in regard to cerebrovascular accidents and myocardial infarction. For patients with acute and chronic dissection with intact aortic root, supracoronary graft replacement is preferred, whereas in those with annuloaortic ectasia with dilated sinus of Valsalva and in all patients with Marfan's syndrome, composite graft replacement has become the procedure of choice.

Phase II study of intra-arterial fluorouracil and mitomycin-C for liver metastases of colorectal cancer.

Effectiveness, toxicity and complications of 5-fluorouracil (FU) and mitomycin-C (MMC) treatment were analyzed in 30 patients with metastatic colorectal cancer confined to the liver. The treatment schedule was FU 2.0-2.5 g/day for 5 days followed by MMC 10 mg/m2 every 2 h on day 6 to a maximum total dose of 60 mg. Treatment courses were repeated every 6 weeks and were given on an outpatient basis via external pump and arterial port systems. In 30 fully evaluable patients, one complete response, 17 partial responses (overall response rate 60%), and stabilization of disease in 8 patients (26%) were obtained for a median duration of 13 months. Median overall survival was 18.2 months (25.5 months for responding patients, 15 months for nonresponders). Grade 1-2 toxicity (WHO classification) consisted of leukopenia (23%), mucositis (20%), nausea/vomiting (16%), and abdominal pain (10%). Two patients (7%) developed severe mucositis. No life-threatening side effects were observed; in particular, there was no sclerosing cholangitis or chemical hepatitis. Catheter-related problems (occlusion, displacement, rupture, infection) occurred in 10 patients (33%) at a median follow-up time of 12 months. We conclude that intra-arterial FU and MMC constitute an effective, safe, and nontoxic treatment in metastatic colorectal cancer confined to the liver. Catheter-related problems are the most important factors limiting treatment.

Long-term complete remission of melanoma liver metastases after intermittent intra-arterial cisplatin chemotherapy and surgery.

This paper presents the case of a female patient with liver metastases of a malignant melanoma showing complete remission after 10 courses of regional, intra-arterial chemotherapy with cisplatin. The drug was administered as continuous infusion for 5 days. The daily dosage amounted to 30 mg/m2. The interval between courses was 6 weeks. Nausea and vomiting were seen after each course, while pathological serum creatinine levels only appeared after the eighth course. The only lesion in the liver still visible on CT scan after chemotherapy was removed by left hemihepatectomy. Meticulous histological examination revealed a big focus of necrotic tissue without any tumour cells. At the time of publication the patient is alive and disease-free over 9 years later.

Long-term results of hepaticojejunostomy for benign lesions of the bile ducts.

BACKGROUND: Hepaticojejunostomy has been the method of choice for the treatment of benign lesions of the extrahepatic bile ducts for years. In the era of minimally invasive and interventional techniques, a review of its long-term results is necessary to set the standard with which these new techniques have to be compared. METHODS: A retrospective analysis was carried out for 51 patients (16 females, 35 males) aged 24 to 83 years (average 48 +/- 13) who had undergone hepaticojejunostomy for benign lesions at our institution between 1980 and 1989. Twelve patients had had up to 4 prior operations of their bile ducts. The main indications for operation were chronic pancreatitis (n = 33) and iatrogenic bile duct lesions (n = 15). If possible, a low end-to-side hepaticojejunostomy was performed. The Hepp-Couinaud approach was saved for high strictures and recurrences. All patients were reassessed by questionnaire at an average of 7.6 years (range 2 to 13) after the operation. RESULTS: Four Hepp-Couinaud and 47 low hepaticojejunostomies were performed. Postoperative complications were seen in 17 patients (33%), 4 of whom had a reoperation. One patient died, for a mortality rate of 2%. The hospital stay averaged 24 +/- 17 days (range 8 to 90). Late complications developed in 13 patients (25%) 2 months to 6 years after the operation. Stenosis and cholangitis necessitated reoperation in 3 cases, cholangitis without stenosis was treated in 4, and other complications were seen in 5 cases. One patient died with a liver abscess, and 12 died of causes unrelated to the operation. When questioned, 31 of 35 patients were in good or very good condition. CONCLUSIONS: Hepaticojejunostomy is a safe and reliable method for the treatment of benign lesions of the bile ducts even in young patients in need of a long-term biliary bypass.

Laparoscopic wedge resection for benign gastric tumors.

BACKGROUND: Both laparoscopic wedge resection and formal laparoscopic resection are used in the treatment of benign and malignant gastric diseases. METHODS: We performed totally laparoscopic wedge resection using stapling devices and three or four trocars. PATIENTS: Four patients were treated with this technique. All four suffered from gastrointestinal stromal tumors (GIST), and one presented with an additional gastric adenoma. Two were morbidly obese, and two had additional operations performed at the same time. Two patients were admitted for acute upper GI bleeding. RESULTS: All of the tumors were removed successfully. Operating time ranged from 135 to 215 min. Oral feeding commenced on days 2-4. Postoperative hospital stay ranged from 5 to 11 days. CONCLUSION: Laparoscopic wedge resection of benign gastric tumors is a safe, reliable method that should be further investigated and used on a broader scale.

The internal mammary artery 'string phenomenon'. Analysis of 10 cases.

The internal mammary artery (IMA) string sign has been described as a narrowing of IMA grafts in the late course after coronary artery bypass grafting. It has been assumed that this phenomenon was due to competitive flow in grafts connected to only mildly stenosed coronary arteries. We analyzed 10 cases of IMA string sign operated on between March 1988 and June 1991. Bilateral IMA was used in six cases and unilateral IMA in four. The mean interval between operation and reangiography was 14 +/- 11 months. String sign of the whole length of the IMA was detected in nine cases, and of the distal part between two sequential anastomoses in one. In all cases, the stenosis of the vessel bypassed with the narrowed graft proved to be only mild (50% or less) at reangiography. In all six cases with bilateral IMA grafts, the contralateral IMA was widely patent. These were all connected to highly stenosed or occluded coronary arteries. With respect to this observation, there is a high index of suspicion that the string phenomenon occurs due to competitive flow in only mildly stenosed coronary arteries. We decided, for our strategy in coronary artery surgery, still to aim at complete revascularization using IMAs as much as possible, but to avoid connecting IMA grafts to only mildly or moderately stenosed coronary arteries.

[Changes in the unmodified vessels after aortocoronary bypass surgery]. / Veränderungen an den Nativgefässen nach aortokoronarer Bypassoperation.

In a prospective study (238 men, mean age 53 years) the changes of the native vessels were studied 3 months after a-c-bypass operation and 5 months after preop. angiography. Progression was defined as increase of stenoses of at least 20% or new total occlusion. Progression was significantly more frequent in vessels with than without bypass and was located proximally to the anastomoses in most cases, less frequently at the anastomoses and very rarely distally to the anastomoses. Proximal progression was significantly more frequent with patent than with occluded bypasses. Stenoses at the anastomoses were significantly more frequent with occluded than with patent bypasses. Stenoses of higher degrees had a stronger tendency for progression than slighter stenoses. Regression was rare and nearly always caused by surgery.

Intussusception of the small bowel due to Peutz-Jeghers syndrome: a case report.

We report the case of a 45-year-old woman with an intussusception of the small bowel due to Peutz-Jeghers syndrome. Immediate laparotomy was performed, and approximately 5 cm of the small bowel had to be removed because of ischemic areas. Six other polyps were removed through buttonhole enterotomies. The Peutz-Jeghers syndrome is rare. Treatment is either surgery or a combination of surgery and intraoperative enteroscopy. Bowel resections must be kept to a minimum.

[Efficacy of basic surgical diagnosis in acute abdominal pain]. / Die Effizienz der chirurgischen Grunddiagnostik beim akuten Abdominalschmerz.

This report describes a retrospective study concerning 314 patients suffering from acute abdominal pain admitted to the surgical emergency unit of Zürich University Hospital in 1992. Basic diagnostic work-up (history, physical examination, blood tests, sonography and abdominal X-ray) revealed the final diagnosis in 188 patients. Sonography was essential in 77 cases. Only 33 patients required additional examinations, such as CT-scan, gastroscopy or contrast X-rays. Ninety-three patients were discharged with a final diagnosis of "non-specific abdominal pain" (NSAP) after their symptoms had improved. A follow-up examination of these patients 6-18 months later resulted in a final diagnosis of somatic diseases in 8% of cases. This study demonstrated that the basic surgical diagnostics are efficient and reveal the final diagnosis with minimal delay. Abdominal sonography is the most important diagnostic tool in this context and should, therefore, be mastered and employed by the surgeon himself.

[Secondary traumatic diaphragmatic hernia with incarceration--a diagnostic problem]. / Zweizeitige, traumatische Zwerchfellhernie mit Incarceration--ein diagnostisches Problem.

In this paper we discuss the case of a 64-year-old patient suffering from a traumatic rupture of the diaphragm with delayed manifestation three years after the trauma. The subsequent diagnostic errors gave rise to a discussion of the value of the physical examination, imaging methods and invasive diagnostic methods, particularly laparoscopy and thoracoscopy in the acute and delayed diagnosis of diaphragmatic injuries.

[Intraoperative ultrasound--an alternative to cholangiography in laparoscopic cholecystectomy? A prospective study]. / Intraoperative Sonographie--eine Alternative zur Cholangiographie bei der laparoskopischen Cholecystektomie? Eine prospektive Studie.

The aim of this prospective study was the comparison of laparoscopic sonography with intraoperative cholangiography (IOC) during laparoscopic cholecystectomy. A 360 degree-sector scanner with a frequency of 5.5 MHz was used. The examination was successful in all 69 patients entered into the study. In the beginning 19 patients were examined sonographically without subsequent IOC. None of these patients had bile duct stones and their postoperative history was uneventful. In the 50 patients operated on subsequently both laparoscopic sonography and IOC were tried. IOC was not performed due to technical failure in 4 patients and due to allergic reactions to contrast media in one patient. Thirty-one patients demonstrated normal bile ducts without stones in both examinations. Ten patients had dilated ducts without stones. In three cases a stone was seen on IOC and intraoperative sonography. In one case a duodenal diverticulum containing debris, demonstrated by IOC, was the reason for a false positive sonographic finding. Sensitivity and specificity of laparoscopic sonography concerning the visualisation of bile duct stones were 100 and 98%, respectively. The time necessary for the examination was significantly shorter in laparoscopic sonography than in intraoperative cholangiography (p = 0.0001). If these results can be reproduced in a larger population of patients, laparoscopic sonography can be considered a safe, fast and non-invasive alternative to intraoperative cholangiography.

[Intraoperative cholangiography and ultrasound in laparoscopic cholecystectomy]. / Intraoperative Cholangiographie und Sonographie bei der laparoskopischen Cholezystektomie.

For years there has been a controversy as to whether or not a routine peroperative cholangiography is indicated during conventional cholecystectomy. With the introduction of the laparoscopic technique, the reasoning has changed, but the controversy persists. The surgeon of today has the choice between two diagnostic modalities, which are to be presented here. Peroperative cholangiography was the technique usually employed during conventional operation. Many surgeons are in favor of routine intraoperative cholangiography during laparoscopic cholecystectomy. The goal of the examination is no longer the detection of unsuspected common bile duct stones, but the visualization of anatomical variations of the bile ducts and hepatic arteries for prevention of bile duct injuries. A difference in number of bile duct injuries in patients examined routinely or selectively has not yet been proven, so selective use of intraoperative cholangiography is still a safe strategy. A multitude of different catheters and introducer-sets for the laparoscopic operation are commercially available. We feel that a catheter should facilitate insertion without requiring the introduction of an additional cannula. An exception are the patients with known bile duct calculi, where a laparoscopic bile duct exploration is planned and the additional cannula is needed for this procedure anyway. Intraoperative cholangiography detects bile duct stones with a sensitivity of 95 to 100%. The sensitivity for the demonstration of anatomical variations of the bile ducts is smaller and anomalies of the arteries can not be demonstrated at all.(ABSTRACT TRUNCATED AT 250 WORDS)

[Initial experiences with the intraoperative sonography in visceral surgery]. / Erste Erfahrungen mit der intraoperativen Sonographie in der Viszeralchirurgie.

Intraoperative sonography (IOUS), which had gained importance from the mid-seventies, was introduced at our clinic in November 1987. To this day, 32 patients have been examined, of which twelve had an examination of the liver, eight of the pancreas and one of the bile ducts. In ten cases surgical strategy was influenced by IOUS. After a comment on the equipment and on the conditions this has to meet, the technique and the difficulties of the IOUS examination of the liver, the pancreas and the bile ducts are discussed. Our own results are compared with those of the literature.

[Long-term course following kidney transplantation]. / Langzeitverlauf nach Nierentransplantation.

The first 100 recipients of cadaveric renal allotransplants operated at our institution between 1964 and 1971 were retrospectively analyzed in terms of a long-term follow-up, complications and survival parameters. Patient and graft survival (indicated in parenthesis) after transplantation were 68% (58%) at 1 year, 50% (38%) at 5 years, 40% (27%) at 10 years, 32% (20%) at 15 years and 20% (13%) at 20 years. Half-life of graft survival was computed using two different mathematical models and was compared with the results of a control group operated in 1986. Half-life was 9.5 years for the study group and 13 years for the control group respectively.