Inspiratory stridor and dysphagia in two newborn infants caused by ectopic thymus tissue.

We report two cases of ectopic cervical thymus, a solid thymic lesion, and a thymus cyst causing inspiratory stridor and mild dysphagia in the neonatal period. Because of the rarity of thymic dystopia, the two masses were initially misdiagnosed as more common entities, namely, lymph node enlargement and lymphangioma, respectively. The correct diagnosis was made only after surgical excision and histopathological examination. This case report is completed by a short review of embryogenic development, diagnostic procedures with differential diagnoses, and therapeutic outcome of ectopic thymus.

Laparoscopically assisted colorectal resection in Hirschsprung's disease.

BACKGROUND: Minimally invasive surgery (MIS) has been adapted to virtually every kind of abdominal operation. Colorectal resections of any extent are possible. The reduction in local and systemic surgical trauma in MIS suggests this method could be valuable for rectal resection for Hirschsprung's disease. - METHOD: Diagnostic work-up is similar to that in open surgery. Three trocars are sufficient, and a fourth may be helpful. Dissection encompasses the entire aganglionic segment and is extended orally to normal bowel.. After complete dissection down to the pelvic floor the bowel is everted transanally, resected in due length and the coloanal anastomosis sutured from outside. Since 1996 four children out of nine (age 11 weeks - 18 years) have been operated laparoscopically at our institution. - RESULTS: There were no intraoperative complications. Recovery time is impressively rapid. Oral intake may be begun on the first postoperative day and physical activity is rapidly restored. There are however problems typical to this method: anastomotic leakage, stricture formation, and the necessity of continuing dilation. - CONCLUSIONS: The feasibility of laparoscopic colorectal resections of any extent is unquestionable. Benefits for the patient seem evident. Prospective randomized studies to provide a higher level of evidence for the benefit of laparoscopy as compared to open technique are difficult to perform due to the small number of patients.

Comparison of economic and environmental impacts between disposable and reusable instruments used for laparoscopic cholecystectomy.

BACKGROUND: The economic and environmental effects were compared between disposable and reusable instruments used for laparoscopic cholecystectomy. Special consideration was given to the processing of reusable instruments in the Miele G 7736 CD MCU washer disinfector and the resultant cost of sterilization. METHODS: The instruments frequently used in their disposable form were identified with the help of surgeons. Thus, of all the instruments used for laparoscopic cholecystectomy, the disposable and reusable versions of trocars, scissors, and Veress cannula were compared. RESULTS: For the case examined in this study, the performance of laparoscopic cholecystectomy with disposable instruments was 19 times more expensive that for reusable instruments. The higher cost of using disposable instruments is primarily attributable to the purchase price of the instruments. The processing of reusable instruments has little significance in terms of cost, whereas the cost for disposing of disposable instruments is the least significant factor. The number of laparoscopic cholecystectomies performed per year does not substantially influence cost. In the authors' opinion, assessment of the environmental consequences shows that reusable instruments are environmentally advantageous. CONCLUSIONS: Considering the upward pressure of costs in hospitals, disposable instruments should be used for laparoscopic cholecystectomy only if they offer clear advantages over reusable instruments.

[Laparoscopic gastric banding in therapy of obesity. Which patients benefit?]. / Laparoskopisches Magenband zur Therapie der Fettsucht. Bei welchen Patienten macht das Sinn?

In view of concomitant illnesses and sequelae associated with significantly increased morbidity and mortality, obesity is considered a major pathological condition. The aim of treatment must be the lasting reduction of overweight. The prerequisite for this is a fundamental change in the patient's inappropriate eating habits, as also other lifestyle aspects. This requires comprehensive and long-term disciplinary management. Within this framework, surgical treatment, in particular the laparoscopic placement of an adjustable gastric band, is the most effective form of achieving weight reduction. The band delays passage of food, and causes early distension of the stomach wall, thus inducing a sensation of satiety. To ensure therapeutic success, nutritional and surgical counseling of the patient has a major role to play.

Dynamic graciloplasty in children with fecal incontinence: a preliminary report.

BACKGROUND: Various therapeutic methods have been developed for anal incontinence. A reconstruction of the sphincter system with functional adaptation can be achieved by stimulation of the transposed gracilis muscle with an implanted stimulator. METHODS: The authors performed a dynamic graciloplasty in 4 boys, aged between 6 and 10 years. Causes for the incontinence were polytrauma with pelvic rupture, VACTERL syndrome with rectal urethral fistula, anal atresia with primary reconstruction and 6 consecutive operations, and coccygeal teratoma in a premature infant with surgical treatment of the recurrent tumour. All children had grade III incontinence. Postoperatively, the duration of stimulation was increased successively by telemetric programming of the pulse generator up to a continuous mode. RESULTS: One child is now almost continent, 2 show grade I incontinence, 1 is incontinent with frequent soiling (the programming has not been completed yet). CONCLUSION: An evaluation of this method for children will not be possible until more operations have been performed, under the conditions of a prospective study, which appears indicated in view of the preliminary but encouraging results presented.

Ergonomics: requirements for adjusting the height of laparoscopic operating tables.

BACKGROUND AND OBJECTIVES: In the last few years many new instruments and devices have been developed and introduced into the operating room (OR). A debate has been ongoing about the optimal ergonomic posture for the operating staff. From practical experience, we have learned that the operating tables cannot be adjusted adequately to allow surgeons of different stature to maintain a comfortable posture. The goal of this study was to establish the most ergonomic table height for the particular physique of the surgeon and the different types of laparoscopic instrument handles that he or she uses. METHODS: In a simulated model, two probands of different stature (50th [BS 50] and 95th [BS 95] percentile) used laparoscopic instruments with four different handle designs (shank, pistol, axial, and rod). The instruments were inserted into a board in three different angles ([IA] = 20 degrees, 30 degrees, 40 degrees). Additionally the elbow angles (EA) of the volunteers were fixed to either 90 degrees or 120 degrees. For every variable (size of surgeon and his or her elbow angle, design of handle, insertion angle of the instrument) the height of the board, as a parameter for the level of the abdominal wall of a patient with pneumoperitioneum, was measured from the floor. RESULTS: All parameters had an effect on the optimal operating table height. The lowest required operating table level was 30 cm, the highest was 60.5 cm. In laparoscopic surgery-long shafted instruments and patients with pneumoperitoneum-the tabletops are too high for over 95% of all surgeons. As skin incision and wound suture are performed the conventional way, the operating tabletop must be adjustable up to the common height of 122 cm. The maximal difference between the optimal heights of the OR-table for one volunteer using two different handles with different insertion angles of the instruments (BS 95, EA 90 degrees, IA 20 degrees, rod handle to BS 50, EA 120 degrees, IA 40 degrees, axial handle) was about 27 cm. CONCLUSION: New operating tables with a much lower adjustability are necessary to fulfill ergonomic requirements. The use of differently designed handles can hinder the ergonomic posture of the surgeon, because each handle requires a different working height.

[Percutaneous placement of feeding tubes for long-term nutrition and decompression. Indications, techniques and complications]. / Perkutane Sondeneinlage zur Langzeiternährung und Dekompression. Indikation, Techniken und Komplikationen.

In the recent past, PEG/PEJ has found worldwide acceptance. The uncomplicated nature of the method has resulted in a considerable increase in endoscopic gastrostomies. Provided that the method is properly applied, and appropriate aftercare is offered, complications rarely occur. In principle, the indications are chronic diseases requiring tube feeding for longer than one month, such as cachexia in patients with cancer or stenotic tumors of the mouth and throat, or of the upper gastrointestinal tract.

[Working posture of laparoscopy-practicing surgeons: ideal and reality]. / Die Arbeitshaltung des laparoskopisch tätigen Chirurgen: Ideal und Wirklichkeit.

Since laparoscopic surgery has been established the advantages for the patients of minimal invasive surgery have been discussed extensively. But this method holds considerable disadvantages, due to the non-ergonomic surgeons working position. This is mainly caused by the false positioning of the monitor and operating table as well by the use of foot switches and differing instrument handles. The common working position of the laparoscopically working surgeon leads to serious risks for the patient. The industry and hospital administrations do not know anything about this and only few surgeons are aware of these dangers. The authors want to draw attention to the insufficiencies of the laparoscopic working place. Due to missing resources until now no general concept has been developed that meets current standards.

[Postoperative peripheral neuropathies in general surgery]. / Postoperative periphere Neuropathien in der Allgemeinchirurgie.

INTRODUCTION: Postoperative nerve lesions beyond the operative area, the so called positioning traumas are considered uncommon in general surgery. But they can have serious consequences for the patient and the surgeon, including forensic sequelae. The objective of this work was to describe the incidence, pattern, risk factors and course of postoperative neuropathies in general surgery and to identify indicators to prevent these complications. METHODS: Based on neurologic records we reviewed all postoperative peripheral neuropathies that occurred in the Department of General Surgery of the University Hospital Freiburg in the time period from January 1979 to December 1990. Lesions that occurred as a direct operative effect were excluded. RESULTS: In 35 patients 50 nerve lesions were observed, representing an incidence of 0.12% of all operations during this time period. Most frequently lesions of the n. peroneus occurred, followed by the n. ulnaris, n. cutaneous femoris lateralis and n. medianus. Nerve lesions were observed in every body position and as early as after 15 min. Postoperative nerve lesions have a favorable prognosis. DISCUSSION: Nerve lesions caused by positioning can occur during any operation with any duration in general surgery. They should be avoided by thorough and careful positioning. Also the patient must be informed about the possibility of nerve lesions caused by the positioning.

Evidence-based surgery: diverticulitis--a surgical disease?

Sigmoid diverticulitis is an increasingly common disorder. While there is no gender difference, the incidence increases with age. Many reports have been published on the topic, but there is no consensus on certain aspects of treatment. We conducted a literature search covering the past 30 years and report our own data. Two major areas of controversy exist. One concerns indications for elective surgery for symptomatic diverticulitis. The consensus is that there is no indication for prophylactic surgery. The first attack should be treated conservatively; elective surgery is considered following a second attack, but in immunocompromised patients earlier. The second controversy concerns surgical strategy in peritonitis from perforation. Three-stage operations have generally been abandoned. The question is whether to perform a sigmoid resection with primary anastomosis. One end of the spectrum is recent perforation which can be treated safely by resection and anastomosis. The other end is advanced feculent peritonitis in high-risk patients. In this situation a Hartmann procedure is recommended. Although data from prospective randomized studies are lacking, there seem to be indicators in the individual situation that allow a rational selection of the appropriate procedure. Diverticulitis can thus be treated surgically for a broad range of its forms of presentation.

A new method for extracting wooden foreign bodies from the upper esophagus.

A foreign body impacted in the esophagus is an emergency case that requires immediate treatment. Often the foreign body can be removed easily using forceps or loops. Sometimes, however, safe grasping and extraction may become very difficult. A patient swallowed a chestnut which then stuck in the upper esophagus. The chestnut was removed with a gynecological instrument with a spiral tip used for myoma fixation. Thereafter this technique was applied to in vitro tests with various kinds of meat and wood. In the clinical case, the chestnut could be removed with the spiral tip of the instrument for myoma fixation, whereas in the in vitro tests it was impossible to grasp meat or cut it into pieces. The removal of foreign bodies, such as wood, with the spiral tip of the instrument for myoma fixation during rigid esophagoscopy is an alternative to extraction with forceps or loops. This method is ineffective for the removal of pieces of meat.

Influence of cytokines on the expression of fas ligand and CD44 splice variants in colon carcinoma cells.

The expression of Fas ligand (FasL) by malignant cells might be a mechanism for tumor immune escape. We investigated FasL expression by LS 174T colon carcinoma cells. Furthermore, the effects of in vitro stimulation with rIL-2, rIFN-gamma and rTNF-alpha were investigated with regard to a possible regulation of the FasL expression by cytokines. FasL expression was detected by flow cytometry and RT-PCR. We observed a spontaneous expression of FasL by LS 174T cells. Incubation with high-dose rTNF-alpha induced an upregulation of FasL of 23%. rIL-2 and rIFN-gamma did not significantly affect FasL expression. To control whether our cytokine stimulation experiments were suitable to prove an upregulation of membrane proteins by tumor cells, we investigated the expression of ICAM-1, N-CAM, CD44s, CD44v6 and CD44v10. These adhesion molecules were spontaneously expressed by LS 174T cells. Only ICAM-1 and CD44v10 were significantly upregulated by rIFN-gamma and rTNF-alpha, respectively. These results could indicate that cytokines, released by tumor-infiltrating leukocytes, may induce the FasL-dependent apoptotic signal by which tumors downregulate an immunological host response.

[Cytokine regulated expression of Fas-Ligand by colon carcinoma cells]. / Zytokinregulierte Expression von Fas-Ligand durch Kolonkarzinomzellen.

We studied the proliferative response of tumor-infiltrating lymphocytes (TIL) from colorectal carcinomas to rIL-2 as well as their cytotoxic activity which was reduced as compared to autologous peripheral blood lymphocytes. We observed TIL to be polyclonal and asked if Fas-ligand-expressing tumor cells are responsible for the elimination of specific T-cells. Therefore we studied the expression of Fas-ligand by LS174T colon carcinoma cells which we showed to be induced by cytokines.

Expression of CD44, ICAM-1 and N-CAM in colorectal cancer. Correlation with the tumor stage and the phenotypical characteristics of tumor-infiltrating lymphocytes.

The cellular adhesion molecules (CAMs) CD44s, CD44v6, CD44v10, ICAM-1 and N-CAM were immunohistologically detected in colorectal cancers using the APAAP method. The expression of CD44s and CD44v6 was associated with the presence of lymph node metastases in the examined tumors. The pattern of ICAM-1 expression was inversely related to that of CD44, i.e. lower numbers of ICAM-1 positive cells were observed in metastasizing tumors. An intense focal staining of N-CAM was observed in the majority of the metastasizing tumors. The expression of CD44v, ICAM-1 or N-CAM on tumor cells did not correlate with the density of the tumor-infiltrating lymphocytes (TIL) within the tumors. The flowcytometric analysis of TIL showed a significant accumulation of CD25+ and HLA-DR+ cells and a reduced number of CD45RA+ cells as compared to autologous peripheral blood lymphocytes (PBL) or intraepithelial lymphocytes of the colon mucosa (IEL). These phenotypic characteristics of TIL did not correlate with the CAMexpression on tumor cells.

[Telesurgery: standards--consultations--continuing education]. / Telechirurgie: Standards--Konsultationen--Weiterbildung.

The aim of the TESUS project is to bring together several European university hospitals in a federation as well as a certain number of clinical centers in a network, the purpose of which is the online and offline transmission of surgical procedure imaging and advice. The innovation is threefold: It provides the surgeon with online information, diagnostic and therapeutic tools and expert advice, the need for which might come up before and during surgical procedures, as well as the same services in the context of teaching and training through regular staff. The developed services will be a major contribution to EU-wide standardisation of health care procedures and therapeutic approaches.