Prospective randomized trial comparing sutured with sutureless mesh fixation for Lichtenstein hernia repair: long-term results.

BACKGROUND: Following Lichtenstein hernia repair, up to 25% of patients experience prolonged postoperative and chronic pain as well as discomfort in the groin. One of the underlying causes of these complaints are the compression or irritation of nerves by the sutures used to fixate the mesh. We compared the level and rate of chronic pain in patients operated with the classical Lichtenstein technique fixated by sutures to patients with sutureless mesh fixation technique. METHODS: A two-armed randomized trial with 264 male patients was performed. After consent, patients were randomized preoperatively. For the fixation of the mesh we used either sutures with slow-absorbing material (PDS 2.0) (group I, n = 133) or tissue glue (Histoacryl) (group II, n = 131). Follow-up examinations were performed after 3, 12 months and after 5 years. RESULTS: Patient characteristics in the two groups were similar. No cross-over between groups was observed. After 5 years, long-term follow-up could be completed for 59% of subjects. After 5 years, 10/85 (11.7%) patients in group I and 3/70 (4.2%) in group II suffered from chronic pain in the groin region (P = 0.108). The operation time was significantly shorter in group II (79 min vs 73 min, P = 0.01). One early recurrence occurred in group II (3 months). The recurrence rate was 0 and 0% after 12 months and 5.9% (5/85) and 10% (7/70) after 5 years in group I and group II, respectively (P = 0.379). CONCLUSION: After 5 years, the two techniques of mesh fixation resulted in similar rates of chronic pain. Whereas recurrence rates were comparable, fixation of the mesh with tissue glue decreased operating room time significantly. Hence, suture less mesh fixation with Histoacryl is a sensible alternative to suture fixation and should be especially considered for patients prone to pain.

Nutritional risk is a clinical predictor of postoperative mortality and morbidity in surgery for colorectal cancer.

BACKGROUND: This study investigated whether nutritional risk scores applied at hospital admission predict mortality and complications after colorectal cancer surgery. METHODS: Some 186 patients were studied prospectively. Clinical details, Reilly's Nutrition Risk Score (NRS) and Nutritional Risk Screening 2002 (NRS-2002) score, tumour stage and surgical procedure were recorded. RESULTS: The prevalence of patients at nutritional risk was 31.7 per cent according to Reilly's NRS and 39.3 per cent based on the NRS-2002. Such patients had a higher mortality rate than those not at risk according to Reilly's NRS (8 versus 1.6 per cent; P = 0.033), but not the NRS-2002 (7 versus 1.8 per cent; P = 0.085). Based on the NRS-2002, there was a significant difference in postoperative complication rate between patients at nutritional risk and those not at risk (62 versus 39.8 per cent; P = 0.004) but not if Reilly's NRS was used (58 versus 44.1 per cent; P = 0.086). Nutritional risk was identified as an independent predictor of postoperative complications (odds ratio 2.79; P = 0.002). CONCLUSION: Nutritional risk screening may be able to predict mortality and morbidity after surgery for colorectal cancer. However, the diverse results reflect either the imprecision of the tests or the small sample size.

[General surgery under discussion. The Swiss model]. / Allgemeinchirurgie in der Diskussion. Das Schweizer Modell.

The need for a general surgical cover, with a high quality standard, following economic principles and offered 24 hours in all regions of Switzerland is not doubted. The title of a "General and Trauma Surgeon" is an additional qualification certified after further successful 4 years post-qualification training following the 6 years specialist title of surgery ('common trunk'). The main field of work encompasses primary emergency surgery as well as 'surgery of the common pathologies' in visceral, vascular, thoracic and partly hand surgery. Due to political reasons the additional qualification in surgical traumatology was completely and exclusively integrated in this sub-speciality title.The post-graduate training to gain the title of a "General and Trauma Surgeon" is mostly completed within 8-10 years and results in the full surgical competence in the above named fields. A major problem is the lack of academic representation of general surgery in the university hospitals resulting in a neglect and increasing difficulties of academic training in this field. Furthermore, there are some recurrent controversies concerning limitations of general surgery in the face of other subspecialities or specialities (e.g. orthopaedics). However, the most important and urgent problem is the lack of the possibility to gain an acknowledged and separate (from general surgery) certification in surgical traumatology, competitive to the specification in orthopaedics. There is no doubt, that, at least in the mid term, there is still a need for general surgeons. At the present moment, the future and the further development of the traumatologist's training under the roof of surgery, at university and regional level is insufficient and is at risk. Therefore, there is an urgent need to address this matter and the Swiss Society of Surgery is taking care of this with priority.

Laparoscopic appendectomy using endoloops: a prospective, randomized clinical trial.

BACKGROUND: Inadequate closure of the appendix stump can lead to abscess formation or peritonitis. This prospective randomized clinical trial was performed to evaluate the number of endoloops needed in laparoscopic appendectomy. METHODS: A total of 208 patients were randomized in two groups: 109 in group 1 using one and 99 in group 2 using two proximal endoloops. The groups were compared in terms of intra- and postoperative complications. RESULTS: Postoperative complications were found in five patients (4.6%) in group 1, consisting of intraabdominal abscesses (three patients), pulmonary embolism (one patient), and persisting port-site pain (one patient). In group 2, postoperative complications were found in five patients (5.1%), consisting of intraabdominal abscesses (four patients) and prolonged percutaneous drainage (one patient). There was no significant difference between the two groups. DISCUSSION: In acute appendicitis, a minimal inflamed appendix base can be safely divided using one endoloop.

Incidence, risk factors, and prevention of biliary tract injuries during laparoscopic cholecystectomy in Switzerland.

Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) which may result in patient disability or death are reported to occur more frequently when compared to open surgery. The aim of this nationwide prospective study beyond the laparoscopic learning curve was to analyze the incidence, risk factors, and management of major BDI. During a 3-year period (1995-1997) 130 items of all LC data were collected on a central computer system from 84 surgical institutions in Switzerland by the Swiss Association of Laparoscopic and Thoracoscopic Surgery and evaluated for major BDIs. Simple biliary leakage was excluded from analysis. There were 12,111 patients with a mean age of 55 years (3-98 years) enrolled in the study. The overall BDI incidence was 0.3%, 0.18% for symptomatic gallstones, and 0.36% for acute cholecystitis. In cases of severe chronic cholecystitis with shrunken gallbladder, the incidence was as high as 3%. Morbidity and mortality rates were significantly increased in BDIs. BDI was recognized intraoperatively in 80.6%, in 64% of cases by help of intraoperative cholangiography. Immediate surgical repair was performed laparoscopically (suture or T-drainage) in 21%; in 79%, open repair (34% simple suture, 66% Roux-en-Y reconstruction) was needed. The BDI incidence did not decrease during the last 7 years. In 47%, BDIs were caused by experienced laparoscopic surgeons, perhaps because they tend to operate on more difficult patients. In conclusion, the incidence of major BDIs remains constant in Switzerland at a level of 0.3%, which is still higher when compared to open surgery. However, most cases are now detected intraoperatively and immediately repaired which ensures a good long-term outcome. For preventing such injuries, exact anatomical knowledge with its variants and a meticulous surgical dissecting technique especially in case of acute inflammation or shrunken gallbladder are mandatory.

[Psychological comorbidity and quality of life of patients with morbid obesity and requesting gastric banding]. / Psychische Komorbidität und Lebensqualität von Patienten mit morbider Adipositas und Wunsch nach Gastric banding.

Bariatric surgical operations are well established in the treatment of morbid obesity. In this study, 79 consecutive applicants for laparoscopic gastric banding (60 females with a mean BMI of 47.4 kg/m2 and 19 males with a mean BMI of 48.9 kg/m2, mean age 39.6 years) were examined preoperatively by structured psychiatric interview and questionnaire. GOAL AND QUESTIONS: The aim of the study was to determine physical and psychological symptoms, specific eating problems, life satisfaction and incidence of psychiatric comorbidity, as well as the relations between psychological and psychosocial markers on the one hand, and demographic and somatic parameters on the other. RESULTS: Most patients displayed multiple somatic symptoms and diseases, in particular orthopaedic problems, exertion dyspnoea, hyperlipidaemia, hypertension, diabetes mellitus or sleep apnoea. The averages of all psychometric scales (General Symptomatic Index of Symptom Checklist [SCL-90-R], anxiety and depression states of the Hospital Anxiety and Depression Scale [HADS]) were higher than normal. General life satisfaction and satisfaction with health (FLZM) were low. Eating behaviour in both sexes was characterised by marked irritability, disinhibition and ravenousness. Binge eating was common, 27% reporting binges at least weekly and only 37% no binges at all. 46% were found to suffer from at least one psychiatric disorder, while half had an eating disorder with frequent bingeing and loss of control. 6.3% were diagnosed with atypical bulimia, 15.2% had an adaptational disorder and 10% a personality disorder. The HADS scales did not correlate with BMI or other somatic factors and the correlation between the SCL-90-R and BMI was low (r = 0.36, p = 0.01). However, patients with psychiatric disorders had significantly higher BMIs and higher averages on all scales except overall life satisfaction. There was no direct relation between psychosocial and sociodemographic variables (educational level, living alone). CONCLUSION: Morbidly obese patients desiring laparoscopic gastric banding display many physical and psychological symptoms with a higher preference for psychiatric (especially eating) disorders. Since there is no close relationship between psychosocial and somatic aspects in this group of patients, routine psychiatric evaluation appears to be of importance.

[Incarcerated and strangulated hernias--surgical approach and management]. / Eingeklemmte und strangulierte Hernien--operativer Zugang und Versorgung.

Acute symptomatic groin hernias with potential or definite ischemia represent a special group of all the groin hernias. The method of choice to treat these hernias has to fulfill the following criteria: 1. Easy reduction of the hernia sac and its contents without causing damage. 2. Good exposure and easy access for possible resection. 3. Safe hernia repair through the same access. According to our experience with 44 incarcerated and strangulated groin hernias operated between 1993 and 1997 and after a literature review, we took the following procedure as our routine: Posterior approach and mesh repair. We do not use a meshgraft only in the presence of colonic necrosis or peritonitis.

["Recurrent appendicitis" 19 years after perityphlitic abscess]. / "Rezidivappendizitis" 19 Jahre nach perityphlitischem Abszess.

We report about a patient who was admitted with acute lower right quadrant pain. She underwent an undetermined operation for appendiceal abscess formation 19 years ago. Our investigations including ultrasound, CT-scan, conventional radiography and finally coloscopy revealed a pericoecal mass formation. Due to worsening of the symptoms, emergency laparotomy was performed. An inflammatory process and a partial necrosis of the coecum wall at the site of the appendix basis were identified und managed by ileocoecal resection and drainage. We took this case to review the literature concerning the treatment of appendiceal abscess and appendiceal mass, and consecutively redesigned our own treatment concept.

Single-trocar-access thoracoscopy for fully optical controlled routine chest drainage: a technical report and feasibility study.

Complications of tube thoracostomy, e.g., organ lesions and malpositioned tubes, are not uncommon. To date, techniques for tube placement have been nonvisualized. The authors believe that a fully visualized penetration of the thoracic wall layers should help to avoid not only perforations and organ lesions but also functionally malpositioned tubes. This article describes a modified endoscopic device, allowing fully visualized and optically controlled access to the pleural cavity for routine chest tube placement. The results of the technical feasibility study for 28 human cadavers showed that it was possible to place the tube as desired. No organ lesions were present. The results suggest that this device and the technique could reduce the risk of complications. The handling of the device is easy and safe. The technique is minimally invasive. The authors' next goal is to prove the results in a clinical study.

3D MR gastrography: exoscopic and endoscopic analysis of the stomach.

The aim of this study was to evaluate the feasibility of MR gastrography, based on 3D MRI following the oral administration of Gd-DOTA-enriched blueberry juice, in order to depict alterations of the gastric wall. The stomachs of three volunteers and three patients were examined on a 1.5-T MR system. Following ingestion of 400 ml of blueberry juice spiked with 2 ml of Gd-DOTA, each subject underwent 3D MR imaging in three positions: 45 degrees left lateral decubitus, supine, and 45 degrees right lateral decubitus. In each position, a coronal 3D SPGR acquisition consisting of 60 continuous 2-mm slices was acquired over a 35-s breathhold (TR/TE = 4.0/1.8 ms, 40 degrees flip angle, 0.5 excitations, voxel size of 1.25 x 1.66 x 2.00 mm). Multiplanar reformats (MPR), maximum intensity projections (MIP), surface shaded displays (SSD), and virtual intraluminal endoscopic views (VIE) were calculated. Magnetic resonance gastroscopy was tolerated well by all subjects without adverse effects. Based on the 3D MRI data sets acquired in various patient positions, all regions of the stomach and the proximal duodenum were visualized to good advantage. Whereas MPR and MIP provided a morphologic overview, SSD and VIE images permitted analysis of the gastric mucosa. Normal mucosa could be differentiated from the course and irregular pattern characterizing carcinomatous infiltration. The 3D SPGR data sets acquired following ingestion of oral Gd-DOTA-spiked blueberry juice permits exoscopic and virtual endoscopic viewing of the stomach.

[Gastric pouch dilatation: complications after laparoscopic implantation of a silicone gastric band in pathologic obesity]. / Die Magen-Pouch-Dilatation: Komplikationen nach laparoskopisch implantiertem Silikon-Magenband bei pathologischer Adipositas.

In 20 patients with morbid obesity a laparoscopic silicon gastric banding was installed using a LAP-BAND. All patients were examined postoperatively with water-soluble oral contrast material according to the usual protocol. 8 weeks after the operation a second control with thickened barium sulfate was added to measure and adjust the width of the silicon band. There were no early postoperative complications. But in the follow-up three patients presented with a pathologic gastric pouch-dilatation. This severe complication, which can have different etiologies, requires early detection and specific therapy.

[Transanal endoscopic microsurgery--experiences at the Zurich University Hospital]. / Die transanale endoskopische Mikrochirurgie--Erfahrungen am USZ.

The advantages of TEM (transanal endoscoic microsurgery) are minimally invasive, exact and full thickness excision of tumors in the rectum and a very low morbidity with excellent comfort for the patient. In a retrospective study all transanal endoscopic operations at Zurich University hospital in the last 5 years have been analyzed (n = 18). 11 adenomas and 5 carcinomas of the rectum have been resected with TEM (one mucosectomy, 16 full wall resections and one segmental resection of the rectum). In the group of the carcinomas there were four preoperatively known carcinomas, one T1 carcinoma was discovered postoperatively in the analyzed tissue. Among the four known carcinomas was one T1 carcinoma, two T2 carcinomas (one of them was thought to be a T1 preoperatively) and one T3 carcinoma. One patient with T2 carcinoma wanted specifically a minimally invasive procedure, the other one with T2 carcinoma was an older patient who didn't qualify for laparotomy. The patient with T3 carcinoma also had a malignant lymphoma. The operation was tolerated well by all the patients. There was one case of peritoneal perforation treated laparscopically and one case of postoperative bleeding. An incontinence of gas in one patient disappeared after 3 months. There was no adjuvant treatment in the group of the T1 carcinomas. One patient with a postoperative T2 carcinoma did not want a chemotherapy. The other two patients with T2 and T3 were polymorbid. Among the resected adenomas there was no case of recurrence. One T2 carcinoma recurred. These results show that transanal endoscopic microsurgery (TEM) is an excellent technique to treat ademomas and T1 carcinomas of the rectum with the advantages of full thickness excision under good vision, a minimal rate of recurrence and maximal patient comfort. The indications for transanal microsurgery are rare. The techically demanding operation is not always simple and should be performed in larger centers only.

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.

[Kidney retransplantation in relation to organ shortage]. / Nieren-Retransplantation im Zeichen des Organmangels.

This article reviews our experience with renal regrafting in the past 16 years with particular emphasis on long-term outcome and prognostic parameters. Among 1094 renal transplants there were 15.8% regrafts, and the proportion of patients awaiting a regraft procedure on our current waiting list is 33%. Graft and patient survival was similar for first and second transplants, but was significantly reduced when a third graft was performed. The main prognostic parameters were the time of function of the previous graft, mismatch for HLA-DR and the presence of panel-reactive antibodies.

Experimental technique for (laparoscopic) bowel anastomosis: transient endoluminally stented anastomosis (TESA).

A new technique for bowel anastomosis is presented. The principle of transient endoluminally stented anastomosis (TESA) is based on anastomosing the two bowel ends around a resorbable stent of polyglycolic acid (PGA) in seroserosal contact. To evaluate the feasibility of TESA for bowel anastomosis, laparoscopic colon anastomosis following sigma resection was performed in five juvenile pigs. Three animals were sacrificed 2 months postoperatively, and the anastomoses were examined radiologically and histologically. One animal was sacrificed at day 2, suffering from acute peritonitis due to small bowel leak but with regular colon anastomosis. One trial was terminated at the fourth postoperative day because of insufficiency of the colon anastomosis. Three animals did not have any complications during the 2-month follow-up. In these animals the colon anastomoses were not detectable radiologically at the time of death. The microscopic examination showed intact mucosal and muscular layers without foreign material. Our study demonstrates that laparoscopic application of TESA to colon anastomosis is a feasible method. These results will further stimulate our future research for an anastomosis technique avoiding remnant foreign material.

In situ repair of aortobronchial, aortoesophageal, and aortoenteric fistulae with cryopreserved aortic homografts.

PURPOSE: The surgical treatment of fistulae that originate from aortic aneurysms or prosthetic aortic grafts carries a high mortality rate. We investigated whether in situ repair with cryopreserved aortic homografts would improve the outcome. METHODS: Between April 1994 and June 1996, 11 patients (mean age, 62 +/- 10 years) with aortobronchial, aortoesophageal, or aortointestinal fistulae originating from mycotic aneurysms (five of 12) or prosthetic aortic grafts (six of 12) underwent in situ replacement of the thoracic (seven of 10) or abdominal (four of 10) aorta with homografts. Emergency surgery was performed in eight of 11 patients (73%). RESULTS: The hospital mortality rate was 9%; there was one sudden cardiac death on the seventh postoperative day. The mean hospital stay was 42 +/- 26 days (range, 21 to 90 days). After surgery, antibiotics were given for 38 +/- 6 days (range, 28 to 42 days). Neither reinfection, suture line rupture, nor anastomotic aneurysms were observed by magnetic resonance angiography, computed tomography, angiography, or transesophageal echocardiography after 14.3 +/- 8.2 months (range, 6 to 31 months). In one patient, percutaneous vascular stent placement was necessary after 18 months for an anastomotic stenosis of a thoracic homograft. CONCLUSIONS: In situ repair with cryopreserved aortic homografts seems to be a promising step in the treatment of aortobronchial, aortoesophageal, and aortointestinal fistulae. This technique has a low operative mortality rate and may prevent reinfection.

[Surgery in malignant obstructive jaundice: laparoscopic surgery--the future?]. / Chirurgie des malignen Verschlussikterus: laparoskopische Operation--die Zukunft?

The systematic staging of pancreatic cancer has facilitated exact evaluation of a patient's prognosis in recent years. Minimally invasive surgery, on the other hand, has produced new procedures which necessitate a distinct dichotomy between open, curative surgery and minimally invasive, palliative procedures. Diagnostic modalities facilitating an accurate assessment of resectability have to be found. Preoperative imaging and endoscopic techniques are only successful in about 50% of cases. Diagnostic laparoscopy is the only method for visualization of peritoneal metastases. The use of diagnostic laparoscopy and laparoscopic sonography raise the accuracy concerning resectability from 20% to between 75% and 100%. 33% up to 67% of patients deemed resectable by preoperative imaging show signs of unresectable cancer at laparoscopy and can be spared an unnecessary laparotomy. For these patients a choice of laparoscopic or endoscopic bypass techniques is available. The laparoscopic hepaticojejunostomy without sutures developed in Zurich has proven to be efficient in animal trials and will soon be implemented in clinical trials. A differentiated indication for laparoscopic bypass techniques and endoscopic stenting is necessary. The laparoscopic procedures should be employed in patients with a risk of duodenal obstruction or a projected mean survival of more than 6 months (stage III), while endoscopic stenting has already been established in the treatment of patients with a survival of less than 6 months (stage IV).