[Intestinal perforation after preoperative colonic tattooing with India ink]. / Darmperforation nach präoperativer kolonoskopischer Tuschemarkierung.

Since the ability to palpate the bowel is lost in laparoscopic colon surgery preoperative marking of lesions is required to avoid "blind" resection. Endoscopic tattooing with India ink is the agent of choice because of its simplicity and the long-lasting stain. Only few complications have been reported using this technique. We present a case with localized necrosis and retroperitoneal perforation after endoscopic tattooing. Due to the formation of a local inflammatoric pseudotumor laparoscopic resection was impossible and open right hemicolectomy was necessary. Fever, abdominal pain and signs of local peritonitis after endoscopic tattooing should remind clinicians of this rare complication.

[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.

[Primary extramedullary plasmacytoma of the duodenum]. / Primär extramedulläres Plasmozytom des Duodenums.

INTRODUCTION: Primary extramedullary plasmacytoma (EMP) is a solitary tumor that arises outside the bone marrow in patients without clinical evidence of coexisting multiple myeloma. EMP represents only 4% of all patients with plasma cell malignancies. The tumor generally occurs in the submucosal tissue of the upper airway or oral cavity. 10% of all EMP occur in the gastrointestinal tract. Only 8 cases of EMP in the duodenum have been reported in literature. METHOD: The authors present a case of EMP in the duodenum in a 53 year old men. The tumor was initially misdiagnosed as desmoid tumor. With a combined treatment of surgery and chemotherapy complete remission for 2 years was achieved, followed by a dissemination of the tumor in the testis, mandibular bone and ribs. CONCLUSION: EMP is a rare differential diagnosis of an intraabdominal tumor. Diagnosis is difficult, and in most reported cases it is confirmed only postoperatively after immunohistochemical staining. Combined treatment of surgery and chemotherapy seem to offer the best potential for cure.

[Role of laparoscopy in the management of acute appendicitis]. / Stellenwert der Laparoskopie für die Behandlung der Appendizitis acuta.

Minimal invasive surgery had a considerable impact on common surgical techniques and has almost replaced established operative procedures such as cholecystectomy. However, the laparoscopic approach for the treatment of acute appendicitis is still not very popular. We discuss the role of laparoscopy for appendectomy and include three studies from our institution (University Hospital Zürich, Switzerland) and prospective studies reported in the literature. We conclude that laparoscopic appendectomy, when compared with the open approach, has the following advantages for the diagnosis and treatment of acute appendicitis. (1) Diagnostic laparoscopy is an effective and relatively atraumatic tool to investigate the abdominal cavity, which results in a sensitivity of almost 100%. This allows for accurate decision making, which is especially advantageous in young women and obese patients. (2) Prospective studies demonstrate that laparoscopic appendectomy is at least as good as open appendectomy and that the laparoscopic approach results in a reduced postoperative infection rate. (3) The similar complication rate after laparoscopic appendectomy, when performed by residents rather than staff surgeons, underlines the feasibility and teaching potential of this minimal invasive procedure.

[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.

[Frozen section diagnosis using telepathology]. / Schnellschnittuntersuchung mittels Telepathologie.

DEFINITION: Since 1992 we transfer digitalized frozen section images by means of videomicroscope and a personal computer through the public telephone network (ISDN) to the Institut of Pathology at the University Hospital in Basel. The aim of this study is to determine whether the quality of frozen section diagnosis obtained by telepathology is comparable to the conventional one. METHOD: The frozen section diagnoses by telepathology from Oct. 1992 to May 1996 (n = 94) are compared to the paraffin sections performed in each case after the primary examination. The result is then compared to the well documented data of conventional frozen section diagnosis in the literature. RESULTS: From Oct. 1992 to May 1996 we performed 94 frozen sections. In 84 cases the diagnosis was correct compared to the paraffin section (89%). The sensitivity to detect a malignant tumor was 92%, the specifity 100%. Four examinations were not conclusive and one examination had to be canceled because of technical problems. DISCUSSION: In the literature, 92% of malignancy is diagnosed by conventional frozen section [1]. Telepathology gives the same result.

Improved growth with bioabsorbable sutures in both high- and low-pressure zones.

BACKGROUND: Compromised growth after operation remains a significant problem in the cardiovascular field. Some benefit of absorbable suture materials has been demonstrated for arterial anastomoses. However, for the low-pressure zone, few data are available. METHODS: To assess growth in high- versus low-pressure zones we transected the abdominal aorta (high-pressure zone) as well as the inferior vena cava (low-pressure zone) in 10 young mongrel dogs using for reanastomosis 7-0 nonabsorbable versus absorbable running sutures in random order. RESULTS: All animals survived and were evaluated over 12 months including body weight (gain, 212% +/- 45% for nonabsorbable versus 218% +/- 8% for absorbable; not significant), angiography, and, after elective sacrifice, detailed studies of aorta and vena cava. Systematic complication of angiographic data at 12 months showed at the suture level an area of 13.8 mm2 for nonabsorbable versus 24.3 +/- 14.4 mm2 for absorbable sutures in the high-pressure zone as compared with 12.9 +/- 4.9 mm2 for nonabsorbable versus 25.3 +/- 15.4 mm2 for absorbable sutures in the low-pressure zone. Residual lumen, calculated as a function of the area above and below the suture, accounted for 35% +/- 10% for nonabsorbable versus 92% +/- 12% for absorbable sutures (p < 0.001) in the high-pressure zone as compared with 37% +/- 13% for nonabsorbable versus 75% +/- 15% for absorbable sutures (p < 0.003) in the low-pressure zone (high versus low, not significant). Poststenotic dilatation accounted for 199% +/- 22% for nonabsorbable versus 126% +/- 43% for absorbable sutures (p < 0.01) in the high-pressure zone. In the low-pressure zone, poststenotic dilatation remained below the inflow area, and the residual poststenotic lumen accounted for 52% +/- 14% for nonabsorbable versus 77% +/- 16% for absorbable sutures (p < 0.004). Macroscopic, light, and scanning electron microscopic studies confirmed different growth patterns in high- versus low-pressure zones. CONCLUSIONS: Aortic narrowing resulted in poststenotic dilatation and unrestricted outflow path (hourglass-type stenosis). Caval narrowing was followed by restriction of poststenotic outflow path (funnel-type stenosis). Absorbable suture material allows for superior growth in both high- and low-pressure zones.

[Perforation of the small intestine in patients with hernia]. / Dünndarmperforation bei Hernienträgern.

Two cases of intestinal perforation associated with inguinal hernia or incisional hernia are presented along with a review of the literature. The great majority are men over the age of 45 with a reducible and usually right-sided inguinal hernia. When a loop of bowel lies opposite a point of weakness in the abdominal wall, such as a hernial orifice, and intraabdominal pressure suddenly rises, the resulting intraluminal pressure ruptures the bowel where it is unsupported. Perforation results in diffuse peritonitis in a few hours. The treatment consists in laparotomy, simple closure of the perforation and drainage of the abdomen. Repair of the hernia is recommended 2 months after healing of the peritonitis. If the complication is early detected and treated the outcome is good.

[Do resorbable suture materials permit safe vascular anastomoses?]. / Erlauben resorbierbare Nahtmaterialien sichere Gefässanastomosen?

Vascular surgery in growing organisms is still problematic. Especially in surgical therapy of coarctation of the aorta, high restenose rates are documented if non-absorbable polypropylene and running suture technique ist used. Theoretically, absorbable suture material allows a running suture technique with less restenose rates. Our study compares absorbable (polyglyconat and polydioxanon) with non-absorbable (polypropylene) suture material for repair of aorta in growing dogs. Anastomoses performed with absorbable suture material show after one year very good functional results without any local complications. In conclusion we can say that absorbable suture material allows formation of safety vascular anastomoses and doesn't impair growth of anastomoses.

[Long-term follow-up of traumatic hip fracture in childhood]. / Langzeitverlauf nach traumatischer Hüftluxation im Kindesalter.

Traumatic hip dislocation is a rare emergency situation in childhood. Long-term follow-up (10 1/12 years [10/12-20 years]) of 9 patients treated at our institution between 1971 and 1992 revealed no late sequelae. There was no case of necrosis of the femoral head. One patient had a recurrent dislocation of the hip 17 and 18 years after the first dislocation. For post-reduction treatment we propose bedrest until pain relief and mobilisation with crutches for 4 weeks. Regular clinical and radiographic controls, including bone scan and/or MRI, are mandatory during the first 2 years.