Adjuvant perioperative portal vein or peripheral intravenous chemotherapy for potentially curative colorectal cancer: long-term results of a randomized controlled trial.

BACKGROUND AND AIMS: The perioperative use of a single course adjuvant portal vein infusion chemotherapy in patients with potentially curable colorectal cancer has been shown to significantly improve overall survival but did not reduce the occurrence of liver metastases (SAKK 40/81) [Swiss Group for Clinical Cancer Research (SAKK) Lancet 345(8946):349-353, 1995]. The objective of the present prospective, three-arm randomized multicenter trial was to assess whether peripheral venous administration of adjuvant chemotherapy regimen based on 5-fluorouracil (5-FU) and mitomycin C decreases the occurrence of liver metastases as well as prolongs disease-free and overall survival. MATERIALS AND METHODS: Stages I-III colorectal cancer patients (n = 753) were randomized to receive either surgery alone (control arm), surgery plus postoperative portal venous infusion of 5-FU 500 mg/m(2) plus heparin given for 24 hours for seven consecutive days plus mitomycin C 10 mg/m(2) given on the first day (arm 2), or surgery and the same chemotherapy regimen administered by peripheral venous route (arm 3). RESULTS: The 5-year disease-free survival for the three treatment groups were 65% (control group), 60% (portal vein infusion, hazard ratio 1.18, p = 0.23), and 64% (intravenous infusion, hazard ratio 1.04, p = 0.76); the 5-year overall survival was 72% (control group), 69% (portal vein infusion, hazard ratio 1.21, p = 0.2), and 74% (intravenous infusion, hazard ratio 1.03, p = 0.86), respectively. A significant accumulation of early deaths were observed in the portal vein infusion group (p = 0.015). CONCLUSIONS: The present prospective randomized multicenter trial provides compelling evidence that short-term perioperative chemotherapy does not improve disease-free and overall survival in patients with potentially curative colorectal cancer. In contrary, the chemotherapy regimen administered in the present investigation seems to have potentially harmful effects, a finding which should be carefully considered in the planning of future trials. Postoperative short-term administration of 5-FU plus mitomycin C either through portal infusion or a central venous catheter is not recommended for routine use in patients with potentially curable colorectal cancer.

Infrainguinal arterial reconstruction with autologous vein grafts: are the results for the in situ technique better than those of non-reversed bypass? A long-term follow-up study.

BACKGROUND: The aim of this study was to answer the question if the in situ technique in infrainguinal arterial reconstruction is better than the non reversed one in long-term follow-up. METHODS: Patients were included in a prospective study at operation. 387 infrainguinal arterial reconstructions in 367 patients performed from 10-88 to 12-98 were retrospectively analysed. RESULTS: 280 non-reversed and 107 in situ bypass procedures were performed. Primary patency rates at 60 months were 63.3% for non-reversed and 57.9% for in situ grafts (p=n.s.). Primary assisted patency rates were 81.8% and 84.5% respectively (p=n.s.). Limb salvage rate was not different in either group. The 30-day mortality was 1.9% in the in situ group and 0.7% in the non-reversed group (p=n.s.). CONCLUSIONS: There is no difference in outcome between in situ and non-reversed vein grafting. Absence of statistical difference between the two procedures may be mainly due to the routine use of angioscopic quality control.

[Surgical dogmas throughout history]. / Chirurgische Dogmen im Wandel der Zeit.

This article is a historical analysis of the role of dogmas and dogmatic thinking in surgery from the great pioneers and teachers of surgery of a hundred years ago to the present time. Medical knowledge applied schematically creates security and may benefit many patients, but when simplification and standardization degenerates into rigid dogma, creative thinking will be obstructed and the development of innovative concepts becomes difficult. In the old times of the 19th and early years of the 20th century, dogmas usually originated from the teaching of great and prestigious pioneers of surgery. Nowadays, dogmatic thinking may come as practice guidelines, protocols of consensus conferences and even from the interpretation of the results of prospective randomized studies. The author illustrates these thoughts by a number of examples taken from the history of surgery over the last one hundred years: The controversy between Sauerbruch's (under)pressurized chamber and the concept of intratracheal positive pressure ventilation and its influence on the development of thoracic surgery during the first half of the 20th century, the role of serendipity and undogmatic thinking in the development of damage control surgery towards the end of the 20th century, the fascinating history of two operations which kept their position as gold standard for almost a century, i.e. Halsted's radical mastectomy for breast cancer and the Miles operation for cancer of the rectum.

[Quality control in patient education. Results of a patient survey about the patient education protocol of the Swiss Society of Surgery in 6 Swiss hospitals]. / Qualitätskontrolle der Patientenaufklärung. Resultate der Patientenbefragung über das Aufklärungsprotokoll der Schweizerischen Gesellschaft für Chirurgie (SGC) in sechs Schweizer Spitälern.

In the past years the number of malpractice suits due to lack of patient information has increased. Because there have been no generally accepted guidelines for preoperative patient information, the Swiss Society of Surgery has decided to work out an informative brochure tailored to the needs of patients. It takes into account that the need to know beforehand is increasing rapidly. In collaboration with the judiciary service of the Swiss Medical Federation all the items and points of legal relevance have been compiled to establish an informative brochure. Based on this protocol, patients in surgical departments of 6 Swiss community hospitals were asked before discharge to qualify the preoperative information offered to them. 2660 questionnaires were evaluated. The majority of patients considered the information regarding their diagnosis, the complications, risks, treatment and postoperative care, the sketches describing the operation and the overall degree of information as good or very good. Almost 60% of all patients stated that no alternative treatment had been discussed with them other than the planned procedure. In most of these patients operative procedures were chosen and carried out for which there were few or no other acceptable options. 2/3 of the patients asked for immediate preoperative written information, especially if they had malignant disease. Barely 4% of the patients were not reassured by the information provided to them. The fact that 2/3 of all patients re-read the informative protocol before the operation underlines how important it is to hand out a copy of the protocol to satisfy the informative needs of the patients. To our surprise the vast majority of patients uttered little concern about giving their signature to forms that were presented to them. Only 2% of the patients felt that giving a signature would cause them grave reservations. The informative protocol devised by the Swiss Society of Surgery is well adapted to the informative needs of the patients and allows for a structured conversation. It facilitates documentation and offers valid legal proof for the physician that he/she has provided adequate information.

Coverage of enterococci in community acquired secondary peritonitis: results of a randomized trial.

INTRODUCTION: The increasing number of enterococcal infections in hospitals and reports about the development of resistance of these bacteria make it necessary to review their importance as co-pathogens in secondary peritonitis. MATERIALS AND METHODS: A prospective randomized controlled trial on primary therapy of secondary peritonitis was carried out in six centers comparing cephalosporin-based antibiotic therapy to acylaminopenicillin-based therapy. RESULTS: Enterococci were only cultured in 6 of 110 cases from the abdomen and were found in only 5 cases of postoperative complications. No differences were found between penicillin-based vs. cephalosporin-based therapy. CONCLUSION: The study supports the view that these bacteria continue to play a minor role in secondary peritonitis. The point has to be emphasized, however, that the patients under study were in relatively good condition (APACHE II median 9 for cephalosporins and 10 for penicillins) and that postoperative cases of peritonitis were excluded.

Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC).

BACKGROUND: This article reports the results of a multicenter prospective audit of totally extraperitoneal (TEP) inguinal hernia repair conducted by the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC) from May 1995 to August 1996. METHODS: At 29 Swiss centers 1,605 inguinal hernia repairs were performed in 1,186 patients. Half of the repairs were performed by operators whose experience consisted of fewer than 51 procedures. Patients were followed up for 1 year. RESULTS: Bilateral repairs were performed in 35% of the patients, and 15% of all repairs were for recurrent hernia. Conversion rates to the transabdominal preperitoneal (TAPP) technique and open surgery were 1.8% and 1.6%, respectively. Main postoperative complications were hematoma and urinary retention. At 3 months, seroma was more frequent with slit prosthesis. The recurrence rate was 0.6% at 3 months and 1.6% at 1 year, not depending on the type of implant. The rate for recurrent hernias did not differ from that for primary repairs. CONCLUSIONS: Total extraperitoneal (TEP) repair can be performed with low morbidity and a high level of patient satisfaction. The effects of the learning curve are not to be neglected. The 1-year recurrence rate is 1.6%. Published data on TEP suggest that late recurrences may be less frequent than after open repair.

Prognostic value of beta1,6-branched oligosaccharides in human colorectal carcinoma.

Increase of beta1,6-branched oligosaccharides is possibly associated with tumor progression and lymph node metastasis. The aim of this study was to determine the prognostic value of beta1,6 branches in human colorectal carcinoma. Expression of beta1,6 branches was histochemically evaluated using the leukoagglutinating Phaseolus vulgaris lectin, PHA-L, in 92 clinically documented colorectal carcinomas, of which 31 had formed lymph node metastases. The follow-up time ranged between 4 and 14 years (median, 10.3 years). A PHA-L staining index (SI), taking into account staining intensity and its percentage of tumor cut surface area, was established. The carcinoma SI was highly associated with the disease-free survival (P = 0.004) and overall survival (P = 0.005). Patients with a carcinoma SI of >1, as compared to those with a SI of < or =1, were at significantly higher risk for tumor recurrence, with a shorter disease-free survival (hazard ratio = 2.59, P = 0.005) and significant higher risk of death with shorter overall survival (hazard ratio = 2.51, P = 0.007). The carcinoma SI was also associated with the presence of lymph node metastases. We conclude that PHA-L staining in human colorectal carcinoma sections provides an independent prognostic indicator for tumor recurrence and patient survival and is associated with the presence of lymph node metastases.

Total mesorectal excision for cancer of the rectum.

The concept of total mesorectal excision (TME) was first described by R. J. Heald in 1982 as a radical cancer operation based on the anatomy of fascial planes and fibrous spaces of the pelvis. The ampulla recti is invested by a fascia propria which is a part of the visceral pelvic fascia. The fascia propria is separated from the parietal pelvic fascia by the pelvirectal fibrous space, which is a compartment of the subperitoneal space of the pelvis. The lateral ligaments of the rectum divides the pelvirectal space into a prerectal and a retrorectal part. TME is defined as the resection of the rectum with its surrounding fatty and lymphatic tissue contained within the visceral sheet of the pelvic fascia. The dissection proceeds in the nearly avascular cleavage plane between the visceral and the parietal fascial sheets, allowing maximal protection of the hypogastric nerves and the inferior hypogastric plexus. Continuity of the prerectal and retrorectal parts of the field of dissection is established by dividing the lateral ligaments of the rectum slightly inside the point where they swing away from the parietal fascia of the pelvic side wall. By following this plane of dissection it is possible to achieve en bloc excision of the total mass of perirectal lymphatic and fatty tissue down to the pelvic floor.

[Toxic megacolon: surgical timing important!]. / Toxisches Megakolon: Operationszeitpunkt nicht verpassen!

Toxic megacolon is defined as a fulminant attack of colitis with total or segmental dilatation of the colon. Toxic megacolon is mostly a complication of nonspecific ulcerative colitis or Crohn's colitis but it may also occur in pseudomembranous colitis and other forms of infectious colitis. Toxic dilatation of the colon is a sign of transmural acute inflammation in which perforation of the colon is impending or may already have occurred. Free perforation means a fourfold increase in the mortality of a fulminant attack of colitis. Dilatation of the colon is not by itself an indication for immediate operation. The dilatation may increase, fluctuate or even disappear, leaving the patient still severely ill with toxic colitis requiring immediate surgery. The indication and optimal timing of surgical intervention require optimal interdisciplinary collaboration between surgeons and gastroenterologists. The procedure of choice for surgical treatment of toxic megacolon is colectomy and ileostomy. The mortality and morbidity of urgent surgery have been decreased by avoiding rectal excision. The rectal stump is either closed as a pelvic Hartmann's pouch or the sigmoid remnant is exteriorized as a mucous fistula or closed subcutaneously. Progress in intensive therapy and perioperative patient management has relegated simple decompression by diverting loop ileostomy and skin-level colostomy as advocated by Turnbull et al nearly 30 years ago to the role of an obsolete procedure which seems hardly ever preferable to resection of the diseased bowel.

Septic complications after biliary tract stone surgery: a review and report of the European prospective study.

We report a prospective, controlled study of the incidence of septic complications following biliary tract stone surgery. This study included a total of 280 patients operated on in eight hospitals in various European countries. In this study the computer program "Surgery" was used. Of 280 patients, 77 (27.5%) were male and 203 (72.5%) were female. The age ranged from 20 to 92 years (mean 54.8 years); 78.9% of the cases corresponded to clean-contaminated surgery; 85% of the patients received antibiotic prophylaxis with cefazolin. Twenty-one patients developed postoperative septic complications (7.5%) of which 12 (4.3%) were wound infections; five patients (1.8%) had intra-abdominal infections. The wound infection rate was 3.2% in clean-contaminated surgery, 7.7% in contaminated and 20% in dirty (p < 0.02). In laparoscopic cholecystectomy the global rate of septic complications was 3.6% vs. 12.6% in open cholecystectomy (p < 0.01); 2.4% and 6.3% wound infection respectively. The mean age of patients who developed postoperative septic complications was 61.5 years and 54.2 years old who did not develop any complications (p < 0.03). The duration of the postoperative period was 5 days in patients without infection and 13 days in patients with infection (p < 0.0001). Two patients died, one of them (0.4%) caused by sepsis. In addition to the European prospective study, a review of the problems of sepsis in biliary surgery was carried out.

[The value of diagnostic peritoneal lavage in emergency situations]. / Der Stellenwert der diagnostischen Peritoneallavage in der Notfallsituation.

PURPOSE: The literature on diagnostic peritoneal lavage in the assessment of blunt abdominal trauma reflects an ongoing controversy. Therefore we conducted a prospective evaluation of the diagnostic management of blunt abdominal trauma used at our clinic, in which this procedure plays a substantial role. During the years 1993 and 1994 a total of 75 patients could be included in the study. The study population consisted of all patients with a diagnosis of blunt abdominal trauma. In addition, all trauma patients who were unresponsive on admission to the emergency receiving unit underwent the same program of diagnostic work-up. This group included polytraumatized patients, patients with craniocerebral injuries and all those who had been intubated prior to admission. Patients with stable vital signs were evaluated first by sonography of the abdomen, whereas those showing signs of hypovolemic shock received a diagnostic peritoneal lavage as the first evaluation of abdominal trauma. In order to assess the relative value of the two diagnostic methods, all patients who had had ultrasound as their first examination subsequently also underwent peritoneal lavage. RESULTS: 37 patients (49%) had lavage evidence of intraperitoneal bleeding. Of these 22 (29% of the total) subsequently underwent emergency laparotomy with lesions requiring surgical treatment found in 21 (95%). Only in one patient (1.3% of the study population) laparotomy failed to reveal a lesion requiring surgical correction. The accuracy of peritoneal lavage findings as an indication for laparotomy was 99%, compared to 82% for ultrasonography used as a initial diagnostic procedure. Diagnostic peritoneal lavage is quick, safe and almost independent of the experience of the investigating physician. It can be performed during other diagnostic procedures and can be repeated at will. If beyond macroscopical evaluation the lavage fluid is assessed chemically, even duodenal and pancreatic lesions as well as injuries to other hollow viscera can be suspected. With a sensitivity of 100% and a specificity of 98%, diagnostic peritoneal lavage is an extremely reliable diagnostic tool. It should be used as the initial diagnostic procedure in all hypovolemic and/or unresponsive patients suspected of having suffered blunt abdominal trauma. In conscious patients with stable vital signs, ultrasonography can be used for initial diagnosis. It should, however, be complemented by subsequent peritoneal lavage whenever the clinical course gives rise to suspicion.

[Necrotizing fasciitis cause by beta-hemolytic streptococci with fatal outcome--a case report]. / Nekrotisierende Fasziitis durch B-hämolysierende Streptokokken mit letalem Ausgang--Ein Fallbericht.

The authors report two cases of necrotizing fascilitis (NF) occurring after surgical interventions on the breast (reduction mammoplasty in one patient and mastectomy for breast cancer in the other). In both cases the etiologic agent were group A pyogenic streptococci and both patients died. NF caused by hemolytic streptococci is a highly lethal disease (over 70% in literature). It starts typically with a purple lesion of the skin, followed by necrotizing fascial infection with secondary necrosis of the overlying skin and rapid progression to septic shock and multiorgan failure. This development is characteristic for NF and allows, together with microbiological results, to distinguish NF from other necrotizing soft tissue infections. Early recognition and aggressive surgical debridement are the mainstays of successful management. Antibiotics and intensive care therapy are indispensable. Hyperbaric oxygen or other supportive therapies do not lower death rate.

[Large Brunner's adenoma of the duodenal bulb--a case report]. / Grosses Brunner'sches Adenom im Bulbus duodeni--Ein Fallbericht.

Benign proliferative changes of the Brunner's glands account for about 10% of neoplasias of the duodenal bulb. Since the first description by Cruveilhier in 1835 about 120 cases have been reported in the English literature. The authors present a case of adenoma of Brunner's gland of unusual dimensions (10 x 5.5 x 2.8 cm). Clinical presentation was by melena, anemia and vague epigastric discomfort. Treatment was by laparotomy with duodenotomy and surgical polypectomy. Proliferative changes of Brunner's glands may manifest as diffuse or localized nodular hyperplasia and Brunner's adenoma. They are localized in the submucosa and small superficial endoscopic biopsies may fail to confirm the diagnosis. Malignancy seems to occur only very rarely with only 14 cases reported in the literature. As the majority of Brunner's adenomas are quite small, endoscopic polypectomy will confirm the diagnosis and cure the condition in most instances. Large symptomatic adenomas may require surgical resection.

[Intraoperative cholangiography in laparoscopic cholecystectomy: a simple, cost-effective techniques]. / Die intraoperative Cholangiographie bei der laparoskopischen Cholezystektomie: eine einfache, kostengünstige Technik.

Description of an easy technique to perform an intraoperative cholangiography (IOC) during laparoscopic cholecystectomy at low cost. After puncture of the abdomen in the right hypochondrium with a commercial vein cannula used as a "mini-trocar", this cannula is mounted by an ureteral catheter (UC). By means of the inlying metal-mandrin the UC can be performed in a slightly curved fashion, which permits an easy cannulation of the Ductus cysticus. Furthermore the mandrin prevents an obstruction of the lumen by the metal clip used to fix the UC in the D.cysticus. After withdrawal of the mandrin the IOC can be performed by use of a commercial syringe fitting to the light-blue plastic adapter delivered with the UC. The method is safe, quick and easy and with a price of less than Swiss francs 10.- per IOC it is unrivalled regarding the costs.

Anatomical basis and rationale of total mesorectal excision.

The concept of TME for cancer of the mid rectum has been introduced by Heald in 1982. Since then the evidence in favor of routinely applying TME in all operable cases of mid and low rectal cancer has kept growing. TME has been shown to reduce the number of R1 resections and increase the number of R0 resections, resulting in a significantly reduced recurrence rate compared to traditional surgical technique. The authors have produced a video which illustrates the anatomical basis and technical details of TME. TME is the resection of the rectum together with the fatty and lymphatic tissue contained within the visceral sheet of the pelvic fascia. This paper details the anatomical basis of TME, describing the fascial structures and fibrous spaces along which the dissection must proceed.

Surgical treatment of hydatid disease of the liver: an experience from outside the endemic area.

BACKGROUND/AIMS: Hydatid disease is quite rare in European countries outside the endemic area around the Mediterranean Sea. Most of the cases observed in Central and Northern Europe occur in emigrants from the endemic area, whose number has been increasing over the last decade. In Switzerland about twenty-five new cases are being diagnosed per year, an incidence of about 0.33 cases per 10(5) inhabitants. Surgery remains the principal treatment modality of hydatid liver disease. There is still debate about conservative surgery as opposed to radical surgical treatment in which the cyst is totally removed including the pericyst by total cystoperi-cystectomy, partial hepatectomy or a combination of both. Surgeons working inside the endemic area tend to favor conservative methods, whereas those outside the endemic area have the tendency to favor radical surgery. This article reviews the results of surgery for liver hydatid disease obtained in a country outside the endemic area. PATIENTS AND METHODS: In our institution 24 patients (12 female, 12 male) have been treated for liver hydatid disease from 6/1983 to 2/1995. Twenty-two patients were immigrants from the endemic area. Surgery indication was primary liver hydatid disease in 23 patients, and recurrent disease in one. RESULTS: Twenty-one patients underwent radical procedures, and three were treated by cystectomy, unroofing and omentoplasty. Radical procedures were pericystectomy in 11 patients, partial hepatectomy in five and pericystectomy combined with partial hepatectomy in five. There was no operative mortality in 23 patients operated on for primary disease, but the only patient operated upon for recurrence died from anaphylactic shock. Eighteen of the 23 surviving patients could be followed up for a median time of 6.5 years (eight months to 12.5 years). Sixteen of 18 patients have remained free of recurrence. One has been reoperated for a retrocaval recurrence four years after right hepatectomy, and one patient is being observed for suspected recurrence after unroofing and omentoplasty. CONCLUSIONS: The policy of applying radical surgery whenever feasible can be followed with acceptable morbidity and near zero mortality. Radical surgery has, however, to be applied judiciously, and there is still an important role for conservative surgery.

Surgical recurrence of perforating and nonperforating Crohn's disease. A study of 101 surgically treated Patients.

PURPOSE: This is a study of the long-term course of surgically treated Crohn's disease designed to identify prognostic factors predictive of the time course and probability of surgical recurrence. PATIENTS AND METHODS: The study is based on the records of 101 patients admitted to our institution for surgical treatment of Crohn's disease from January 1, 1970 to December 31, 1985. Follow-up was complete in 97 (96 percent) and incomplete in 4 patients. Median follow-up from the date of first operation was 13.25 years. The cumulative probability of requiring surgical treatment for recurrent disease was calculated using the life table method and further analyzed with the log-rank test and Cox regression. RESULTS: The time to reoperation in this series was not significantly influenced by sex, age at onset of symptoms, age at diagnosis, age at first operation, anatomic location, and number of sites involved at the time of first operation. The only variable that had a statistically significant effect on the time to reoperation was characterization of disease at the time of operation as being perforating (P) opposed to nonperforating (NP). Median interval between the first and second intestinal operation was 1.7 years for the P group and 13 years for the NP group (P value, 0.005), and the median time between any two operations undergone during the study period was 2 years for the P group and 9.9 years for the NP group (P = 0.0002). The risk of having to undergo reoperation for recurrence was greatest during the first two years after an operation, and this was mainly because of a short time to surgical recurrence in the P group of indications. Therefore, the yearly hazard of requiring further surgery was maintained at approximately 5 percent. CONCLUSION: The cumulative probability of requiring a reoperation for patients undergoing surgery for the P type of Crohn's disease is significantly different from that of patients with NP indications. The risk of having to undergo further surgery is particularly high during the first two years following an operation for perforating disease. The concept of a relatively aggressive perforating type of Crohn's disease and a more indolent nonperforating type is confirmed by the results of this study.

Early hematological toxicity of adjuvant perioperative intraportal and intravenous chemotherapy with fluorouracil, mitomycin and heparin in colorectal cancer. Swiss Group for Clinical Cancer Research.

BACKGROUND: From 1987 to 1993 the Swiss Group for Clinical Cancer Research (SAKK) performed a randomized phase III adjuvant trial in patients with colorectal adenocarcinoma with the objective of comparing intraportal versus intravenous perioperative chemotherapy. PATIENTS AND METHODS: Patients younger than 75 years had a curative en bloc resection of their cancer and were then randomized into three arms: 1. adjuvant perioperative portal liver infusion with fluorouracil, mitomycin and heparin, 2. adjuvant subclavian intravenous infusion with the same regimen and 3. no adjuvant treatment. The hematological toxicity was evaluated by hemoglobin determination and leucocyte and thrombocyte counting before and during ten days after surgery. RESULTS: Hemoglobin showed a median decrease of 22% in the control group. This decrease is aggravated significantly by 3% through the chemotherapy. Leucocytes showed a median decrease of 7% in the control group. Perioperative chemotherapy caused a significantly higher median drop; 23% when given into the liver through the portal vein and 34% when given systemically through a subclavian catheter. Thrombocytes revealed a median decrease of 25% in the control group. Chemotherapy was not associated with a significant additional drop. CONCLUSIONS: Adjuvant perioperative chemotherapy with fluorouracil, mitomycin and Heparin as given in this study is associated with a significant mild drop in hemoglobin and leucocytes during the first 10 postoperative days. If drug dose increases are planned in future trials the addition of hematopoietic growth factors might be considered.

[Fasciola hepatica--a unusual cause of acute cholecystitis with cholestatic jaundice]. / Fasciola hepatica--eine seltene Ursache der akuten Cholezystitis mit cholestatischem Ikterus.

A 29-year-old patient was admitted with acute abdomen in the 17th week of pregnancy. History revealed two episodes of colic in the right hypochondriac area during the previous six months, but no other abdominal complaints. Clinically the picture was that of acute cholecystitis. Laboratory findings included an elevated white cell count, a slight elevation of serum transaminases and a marked increase of serum alkaline phosphatase and bilirubin. Echographically there were dilated intra- and extrahepatic bile ducts containing two hyperechogenic elements without casting an acoustic shadow. A hydrops of the gallbladder with sludge and a thickening of the wall could also been seen. Because of pregnancy an ERCP could not be performed due to the need for X-ray, so we had to resort to open surgery. Under tocolytic and antibiotic shielding we carried out open cholecystectomy and choledochoscopic exploration of the common bile duct. Using a Fogarty balloon catheter we extracted two live, adult liver flukes and placed a T-tube in the duct. Because of positive fecal probes for fasciola eggs the T-tube had to be left in place until childbirth. Afterwards we performed a pre-cut-papillotomy by ERCP and took the T-tube out, having confirmed a clear duct on a T-tube-cholangiogram. With negative fecal probes and the eosinophilia on the white cell count returning to normal, we decided against the planned chemotherapy and assumed self-healing of the disease. The patient has been well since.(ABSTRACT TRUNCATED AT 250 WORDS)

Infrainguinal arterial reconstruction with non-reversed autologous vein after angioscopy guided valvulotomy ex situ.

AIMS: The advantages of in situ autologous vein grafts for long infrainguinal arterial reconstructions are the tapered conduit, minimising size mismatch at proximal and distal anastomoses, and the possibility of using small sized veins with good results. Unfortunately, in about 30% of legs the ipsilateral saphenous vein is inadequate rendering in situ bypass grafting impossible. To profit from a valveless autologous vein graft in these cases we routinely performed ex situ valvulotomy after harvesting the contralateral saphenous vein or good quality segments of the ipsilateral saphenous vein. METHODS: The ex situ valvulotomy was performed under angioscopic guidance using a flushing-type Mill's valvulotome. RESULTS: Fifty non reversed grafts in 46 patients entered a prospective surveillance program. Primary and primary-assisted patency rates at 2 years were 68% and 82% respectively, early graft thrombosis 2%, late stenosis 8% and major amputation rate with a patent graft 6%. No technique related problems were noticed. CONCLUSION: Angioscopy guided valvulotomy was safe and simple and allowed good quality control of the veins. The presented results in this study are comparable to other recently reported series of in situ bypass. The clinical use of small flexible endoscopes allows a safe and atraumatic valvulotomy and simultaneous quality control of autologous vein grafts.