Pharmacological blocking of the osteoclastic biocorrosion of surgical stainless steel in vitro.

In vitro studies suggest that human osteoclasts (OC) are able to corrode surgical stainless steel 316L (SS). The aim of this study was to investigate whether osteoclastic biocorrosion can be blocked pharmacologically. Human OCs were generated in vitro from peripheral blood monocytic cells (PBMCs) in the presence of OC differentiation cytokines. The osteoclastic viability, differentiation, and resorptive function (on both bone and SS) were assessed using standard colorimetric cell viability assay 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenil)-2H-tetrazolium, inner salt (MTS), fluorescence microscopy, tartrate-resistant acid phosphatase expression (flow cytometry), and scanning electron microscopy. OCs cultured on SS were exposed to nontoxic concentrations of bafilomycin A1, amiloride hydrochloride, or zoledronic acid. The extent of biocorrosion was quantified using atomic emission spectrometry (to measure the concentration of metal ions released into the supernatant) and scanning electron microscopy. PBMCs differentiated into mature and functional OC in the presence of all the drugs used. Osteoclastic resorption of SS was noted with differences in the resorption pattern for all drug treatments. Under the drug treatments, single areas of osteoclastic resorption were larger in size but less abundant when compared with positive controls. None of the drugs used were able to inhibit osteoclastic biocorrosion of SS.

Incarcerated vermiform appendix in a left-sided inguinal hernia.

We report here of a patient with an incarcerated vermiform appendix occurring in a left-sided indirect inguinal hernia. Occasionally, appendices are found in a hernial sac; however, the finding of an incarcerated vermiform appendix in an inguinal hernia on the left side is very unusual and has only been previously described once. The patient suffering this rare entity underwent appendectomy and repair of the hernia and experienced an uneventful postoperative recovery. The possibility of the presence of a situs inversus, or malrotation, as an underlying cause for the observed pathology was excluded by x-ray examination.

[Trusses in the current management of hernia]. / Stellenwert der Bruchbandtherapie im Zeitalter moderner Hernienchirurgie.

To assess the frequency and reasons for truss prescription, we surveyed 437 general practitioners collaborating with the surgical department of the Kantonsspital Winterthur and all members of the Swiss Association of Orthotists. 59% of the general practitioners answered. For 85% of them trusses are obsolete. Based on the data of the orthotists, an estimated 1740 trusses are issued in Switzerland annually (250 per million population). In Switzerland approximately 16,000 hernia operations are performed annually. Therefore, 11% of hernia patients are supplied with a truss rather than referred for a consultant surgical opinion. Patients can be divided into groups, one that wears the truss only for a short time in order to delay surgery for medical or occupational reasons and another group, especially elderly patients, that wears the truss permanently. Poor hernia control and pain, hernia incarceration, or dissatisfaction with the uncomfortable truss are reasons for referral to a surgeon. In our personal experience with 14 patients, all judged their situation after the operation better than with the truss. Our study confirms that despite advances in hernia surgery and in the use of regional and local anesthesia trusses are often prescribed.

[Effect of new technologies on diagnosis and therapy of acute appendicitis]. / Der Einfluss neuer Technologien auf Diagnostik und Therapie der Appendicitis acuta.

Acute appendicitis remains a diagnosis based primarily on the history and the physical examination performed by an experienced surgeon. Ultrasonography and CT can be an useful adjunct, but they should not be used without context to the clinical picture. In therapy, open appendicectomy remains the golden standard. Laparoscopic appendectomy is reserved for special situations. Preoperative ultrasound is useful to decide upon the operative procedure. When the clinical picture and ultrasonography reveals acute appendicitis one can expect a minimal negative appendectomy- and laparotomy rate of 2.7% and 2.1%. In these situations open appendectomy is indicated. In the case where ultrasonography reveals no appendicitis, negative appendectomy rate is 31%. In this situation further abdominal exploration and thus diagnostic laparoscopy and laparoscopic appendectomy is indicated.

[Postoperative heparin-induced thrombopenia with thromboembolism (HITT)--a rare complication of heparin therapy?]. / Postoperative Heparin-induzierte Thrombopenie mit Thromboembolie (HITT)--Eine seltene Komplikation der Heparintherapie?

Many surgical patients receive either unfractionated or low-molecular weight heparin in a prophylactic or therapeutic intention. Feared upon the administration of heparin is the heparin-induced thrombopenia (HIT). In HIT type 1, the heparin directly interacts with the platelets. The platelet count rarely falls below 100,000/microliter and normalizes again despite continuous administration of heparin. In HIT type 2 or HIT with thrombosis (HITT) the platelet count usually falls more than 50% and due to an antibody-dependent platelet activation, thromboembolic episodes may occur. Compared to non-surgical patients, the incidence of HITT in the postoperative phase is markedly increased. In suspicion of a HITT, heparins should immediately be stopped and replaced by an alternative coagulant because of a high risk of further thromboembolic complications. Direct thrombin-inhibitors such as the recombinant hirudins are considered to be safe and effective. They have no heparin-like immunological properties and therefore, they seem to become the therapeutic and prophylactic "gold-standard" in patients with HITT.

[Ogilvie syndrome with cecal perforation. A rare complication after isolated thoracic trauma. Case report and current literature review]. / Das Ogilvie-Syndrom mit Zökumperforation. Eine seltene Komplikation nach isoliertem Thoraxtrauma. Fallbericht und aktuelle Literaturübersicht.

In reviewing 750 cases of acute colonic pseudo-obstruction from the literature, the most commonly associated disorders are listed and the therapeutical management is critically discussed. The authors describe an additional case of a 77-year-old male with ogilvie's syndrome following isolated thoracic trauma. Ogilvie's syndrome has been used synonymously with acute colonic pseudo-obstruction (ACPO) of the colon, first defined by Sir Heneage Ogilvie in 1948. If inappropriately managed, the massive colonic dilatation may lead to caecal ischaemia and perforation with a high mortality rate. Aetiology and pathogenesis of the syndrome are still unknown, but mostly ACPO is associated with a wide variety of medical conditions. Often it appears to be a complication after abdominal or pelvic surgery or trauma. In few cases the pseudo-obstruction is isolated and therefore truly idiopathic. Conservative treatment is indicated if the caecum is less than 12 cm in diameter. If there is a progressive increase in diameter or no improvement is seen, the colon should be decompressed without further delay. The indications for surgery are failure of conservative treatment and colonoscopy, signs for ceacal ischaemia or perforation. The choice of procedure, coecostomy or resection, is dictated by the state of the caecum. Due to a high mortality rate (up to 50%) if the caecum is perforated, an aggressive therapeutical management should be applied.

[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.

[Idiopathic segmental fatty tissue necrosis of the ligamentum teres hepatis. Variation on a theme...]. / Idiopathische segmentale Fettgewebsnekrose des Lig. teres hepatis. Variation eines Themass....

INTRODUCTION: Idiopathic segmental infarction of the peritonealized intra-abdominal fatty tissue is a rare cause of acute abdominal distress. Patients are operated for by suspected acute appendicitis or cholecystitis, and the true diagnosis is made intraoperatively. METHODS: A 32-year-old woman was admitted to our hospital with a 2-day history of pain in the right upper abdomen. Clinical presentation suggested acute cholecystitis, but laboratory evaluation and sonography revealed no pathological findings. Because of a distinctly palpable and very painful epigastric tumor 2 x 3 x 3 cm, a CT scan was performed, that showed a clearly circumscribed mass in the ligamentum teres hepatis with hyperattenuating, infiltrating streaks. Laparoscopy was performed, and a tumor was found, that was adherent to the stomach's antrum and could easily be resected. Twenty-four hours after surgery the patient only felt slight discomfort and could be dismissed on the second day. Pathology report revealed a hemorrhagic infarction of the fatty tissue, which can be histologically found in idiopathic segmental necrosis of the greater omenum or the appendices epiploicae. CONCLUSIONS: Laparoscopy is an excellent diagnostic tool and also has therapeutic possibilities. Resection of the necrotic tissue ensures faster recovery and pain control and should be performed to prevent complications such as bacterial superinfection with formation of an abscess or spontaneous bleeding.

Gastrointestinal stenting.

Acute obstructions of the gastric outlet, the duodenum, or the large bowel require rapid treatment to relieve symptoms of retention or ileus. Large-caliber stents of 16 to 22 mm offer a new non-surgical alternative for treating these patients with minimal risks and high success rates. For gastroduodenal outlet obstructions palliated by self-expanded metal stents, clinical success rates are in the range of 80-100 %. Preoperative treatment of colorectal obstructions successfully relieves acute symptoms of ileus in 87-100 % allowing primary anastomosis and thereby reducing the costs caused by multiple operations and the need of intensive care by approximately 25 %. It is the purpose of this review to familiarize the reader with the indications, possibilities, and limits of intestinal stenting.

[Benign liver tumors: diagnosis and therapy--a review]. / Benigne Tumoren der Leber: Diagnostik und Therapie--eine Ubersicht.

Advances in abdominal imaging technology in the past 20 years and their widespread application have improved the detection of benign liver tumours. The three most common tumours of this type are hepatic adenoma, focal nodular hyperplasia and haemangioma. Besides these three, other benign tumours of the liver are less important because of their rarity. Diversity of and technical advances in imaging technology make the choice of diagnostic approach difficult. Ideally, a test should be non-invasive, low-risk and commonly available, with high specificity and sensitivity. Therefore, we use sonography as a screening method and MRI as a secondary diagnostic procedure. The value of diagnostic procedures is discussed. Therapy and outcome of each tumour is outlined.

[Inguinal hernia 1998--an assessment of current status]. / Leistenhernienchirurgie 1998--eine Standortbestimmung.

Hernia surgery has considerably changed in recent years. In the era of minimal invasive surgery classical Shouldice repair has become old-fashioned and is increasingly replaced by tension-free techniques using synthetic mesh material. Currently, Shouldice repair remains the treatment of choice in young patients with small primary hernia. Lichtenstein hernioplasty is indicated in young patients with large hernias, and in those over 35 years of age for any size of hernias. Endoscopic operations are restricted to bilateral primary hernias and recurrent hernias. In future, when used on the basis of a reasonable strategy, the variety of operative procedures offers a chance to improve the results of hernia surgery. Further studies are needed to demonstrate which hernia strategy is most reliable in terms of cost-effectiveness, patient comfort, complication and recurrence rate.

Acute colonic obstruction: clinical aspects and cost-effectiveness of preoperative and palliative treatment with self-expanding metallic stents--a preliminary report.

PURPOSE: Evaluation of clinical aspects and cost-effectiveness of use of self-expanding metallic stents in the treatment of acute colonic obstruction as either a preoperative procedure or palliation. MATERIALS AND METHODS: Thirteen consecutive patients, aged 49-83 years (mean, 67 years), with clinical and radiologic signs of colonic obstruction were treated as a preoperative procedure in 10 patients and as a palliative treatment in three. A total of 16 self-expanding metallic stents (diameter, 16 mm; length fully expanded, 56 mm) were implanted with combined fluoroscopic and endoscopic guidance. The costs (hospitalization, intensive care unit, stent placement, and surgery) were compared with costs for 13 surgically treated patients at the same hospital. RESULTS: Stent placement was successful in 12 of the 13 patients; all recovered from mechanical obstruction, and single-stage surgery was possible in eight of nine patients treated preoperatively. One very narrow stenosis could not be passed. Dysfunction occurred in two long stenoses after 5 days with reocclusion 2 and 6 weeks, respectively, after stent placement. A cost reduction of 19.7% was observed as a result of shorter hospitalization and a lower complication rate. In patients with colon cancer in the preoperative treatment group, the cost reduction increased to 28.8%. CONCLUSION: Metallic stent placement in patients with acute colonic obstruction was a minimally invasive and cost-effective preoperative procedure that allowed single-stage surgery in most cases. Stent placement for palliation should be limited to patient with special indications.

[Postoperative ileus--early, late or no surgery at all?]. / Postoperativer Ileus--Früh, spät oder gar nicht operieren?

One third of all relaparotomies are due to early postoperative bowel obstructions. Operations on the small bowel and colon are predominant among the primary procedures. The main causes of obstructions are adhesions. The symptoms of intestinal obstruction in the early postoperative period can be masked by a prolonged postoperative ileus. Reoperation of bowel obstruction is easier and safer in the first ten postoperative days compared to delayed reintervention after unsuccessful conservative treatment. When obstruction occurs after the first postoperative week, an initial conservative therapy for 7 to 10 days can be successful in over 50%.

Hemosuccus pancreaticus as a source of obscure upper gastrointestinal bleeding: three cases and literature review.

We report three patients with chronic pancreatitis and recurrent episodes of severe upper gastrointestinal bleeding caused by hemosuccus pancreaticus. No bleeding source could be identified despite repeated endoscopies. In two patients, angiography disclosed a fistula between a peripancreatic artery and a pancreatic pseudocyst. In one patient, a fistula between the splenic artery and the pancreatic duct was found intraoperatively. No rebleeding occurred after operation. In cases of obscure upper gastrointestinal hemorrhage, the pancreas should be considered as a bleeding source, especially in patients with chronic pancreatitis.

Preoperative diagnosis of Meckel's diverticulum by pertechnetate scan and laparoscopic resection.

Acute lower gastrointestinal hemorrhage in a 17-year-old boy was caused by a Meckel's diverticulum 1 day after ingestion of 500 mg acetylsalicylic acid. After conservative treatment of the bleeding, the diverticulum was diagnosed in the free interval by technetium pertechnetate scintigraphy, which showed an accumulation in the right lower quadrant simultaneously with the accumulation in the gastric mucosa. Elective explorative laparoscopy confirmed the diverticulum, and the resection was performed by laparoscopic means. Histology showed gastric-type mucosa in the diverticulum. The treatment of choice for Meckel's diverticulum, when it is diagnosed preoperatively or during laparoscopy, is laparoscopic resection.

[Results of surgery in hepatic echinococcosis]. / Resultate der Chirurgie bei Leberechinokokkose.

Echinococcosis of the liver is a disease rarely seen in Switzerland. E. alveolaris is the parasite causing the indigenous cases, while most of the patients infected by E. cysticus have migrated from the Mediterranean region. 26 patients suffering from echinococcosis of the liver were treated at the Department of Surgery of Zürich University Hospital between 1983 and 1992. There were 12 female and 14 male patients aged between 21 and 72 years (mean: 41 yrs). In 6 cases the cause was an infection with E. alveolaris (group 1), all the other patients suffered from E. cysticus infection (group 2). In group 1, there were 3 segmentectomies, 2 hemihepatectomies and 1 exploratory laparotomy. In group 2, 16 patients underwent pericystectomy. Furthermore, 1 hemihepatectomy, 3 atypical resections and 2 segmentectomies were performed. Complications were seen in 100% in group 1 and in in 35% in group 2, respectively. 2 patients died postoperatively for a mortality of 8%. We concluded that infections with E. alveolaris are rarely resectable without increasing drastically the risk of the operation. Therefore, postoperative long-term chemotherapy is necessary. Operations for both types of echinococcosis are fraught with a high rate of complications.

[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.

[Opportunistic infections in patients with disordered immune status]. / Opportunistische Infektionen bei Patienten mit gestörter Abwehrlage.

Dysfunction of the immune system can result in opportunistic infections, which are frequently responsible for high morbidity and mortality. With regard to surgery, opportunistic infections are found in specific risk groups, including individuals with tumors, AIDS, thermic or mechanical trauma and organ transplantation. These infections can be caused by bacteria, fungi, viruses and protozoa. If there are indications of a possible opportunistic infection, a rapid diagnosis is required, followed by immediate therapeutic intervention.

Latex agglutination test for cytomegalovirus antibody screening of transplant donors. Important aspects.

In a retrospective study, false negative readings of CMV Scan results were detected. In a following prospective survey of 72 transplant donor sera, CMV Scan had a sensitivity and a negative predictive value of greater than 95%. Although CMV Scan is a rapid and useful test, a higher reliability can be achieved if results are controlled by another sensitive test or, at the least, CMV Scan is read by two different persons.