[Course system of the Working Group for Gastro-intestinal Surgery Davos]. / Kurssystem der Arbeitsgemeinschaft für Gastrointestinale Chirurgie Davos.

Training in technical skills is essential for advanced surgical education. Training is moving more and more from the operating room to surgical training laboratories. A crucial impulse for this development came from Davos, where the first skills course was organized in 1984 after the formation of the Working Group for Gastro-intestinal (GI) Surgery (AGC Davos). Since this first course more than 5,000 residents have successfully completed the GI skills training course in Davos and many of the alumni are themselves teaching surgery today. The level and quality of this course has remained stable for 27 years on a high quality level although teaching has continuously been adjusted to modern techniques. The language of this international workshop is English. The number of applications exceeds the course capacity every year, which is an indication for the need of such training courses and should be principally included into the skills curriculum for surgeons.

[Laparoscopic and conventional cholecystectomy. Didactic concept for training and introduction of laparoscopic cholecystectomy and preventing complications]. / Cholezystektomie laparoskopisch und konventionell. Didaktisches Konzept zur Ausbildung und Einführung der laparoskopischen Cholezystektomie und zur Vermeidung von Komplikationen.

AIM: This study has assessed the suitability of an educational concept for the introduction and training of laparoscopic cholecystectomy, a newly established operational procedure, within an university teaching hospital with a large number of surgeons. PATIENTS AND METHODOLOGY: Since introduction of the first laparoscopic cholecystectomy all cholecystectomies were prospectively assessed over a period of two years (from May 1990 till May 1992). The educational concept applied was such that a given surgeon would first receive training from an instructor for 15 procedures and then assume responsibility for instruction of a subsequent trainee. RESULTS: In two years 355 patients underwent cholecystectomy. 60% of the operations were performed laparoscopically and 40% of the operations performed openly. During the two year period 13 surgeons were trained in the new technique, with an average of 16 operations per surgeon. Throughout the introductory phase there were no serious complications, and in particular no damage to the bile duct. DISCUSSION: The advantage of this introductory training phase has repeatedly been subject of discussion in the literature. In the meanwhile guidelines from specialist bodies and national institutions exist for regulating the education of new surgical techniques. In the past few years introduction to new techniques has gradually shifted toward training on the skill-stations and virtual reality trainers. CONCLUSION: The described educational concept for the introduction and training of laparoscopic cholecystectomy has been well approved and accepted since the early 90's.

Intestinal ischemia after bushmaster (Lachesis muta) snakebite--a case report.

After a snakebite by the Costa Rican bushmaster Lachesis stenophrys, a 64-year-old patient developed cardiovascular shock and coagulopathy. After intensive care and antivenom treatment, he was discharged after 4 days but had to be hospitalised again 3 days later because of abdominal pain and bowel obstruction. An emergency laparotomy revealed a necrotic ileum and caecum, and an obstruction of the superior mesenteric artery. Until now, this type of intestinal ischemic complication after a snakebite has not been reported in the literature. The effects of bushmaster venom are discussed.

[Post-traumatic pancreatic pseudocyst in a child]. / Posttraumatische Pankreaspseudozyste beim Kind.

Pancreatic pseudocysts are rare in children. Traumatic injury accounts for 80% of the cases. We present the case of a pancreatic injury with pseudocyst formation in a child and discuss the initial management of pancreatic injury as well as the treatment of pseudocyst formation in children.

Cervical lymphadenitis--a rare case of focal listeriosis.

Cervical lymphadenopathy is a condition with a broad differential diagnosis. Malignant tumors, allergic reactions, autoimmune diseases as well as various infectious agents can be the cause. We report the case of a 75-year-old man who had a cervical lymphadenopathy without symptoms of infection. The draining lymph nodes were excised. Histology revealed a granulomatous abscess and culture yielded pure growth of Listeria monocytogenes. Because food is occasionally contaminated with L. monocytogenes, the pathogenesis of this condition may be similar to that of lymph node tuberculosis.

Prevalence of Helicobacter pylori infection in peptic ulcer perforations.

BACKGROUND: Most patients with chronic peptic ulcer disease have Helicobacter pylori (H. pylori) infection. In the past, immediate acid-reduction surgery has been strongly advocated for perforated peptic ulcers because of the high incidence of ulcer relapse after simple closure. Simple oversewing procedures either by an open or laparoscopic approach together with H. pylori eradication appear to supersede definitive ulcer surgery. METHODS: In 47 consecutive patients (mean age = 64 years, range 27-91) suffering from acute peptic ulcer perforation the preoperative presence of H. pylori (CLO test), the surgical procedure (laparoscopy or open surgery), the outcome of surgery, and the success of H. pylori eradication with a triple regimen were prospectively studied. RESULTS: Of these patients 73.3% were positive for H. pylori, regardless of the previous use of nonsteroidal anti-inflammatory drugs (NSAIDs). Thirty-eight per cent underwent a simple laparoscopic repair. Conversion rate to laparotomy reached a high of 32%. The main reasons for conversion were the size of the ulcer, and/or diffuse peritonitis for a duration of over 12 hours with fibrous membranes difficult to remove laparoscopically. In the H. pylori positive patients, eradication was successful in 96% of the cases. Mortality and morbidity rates were greater in the laparoscopic group (p < 0.05). Follow-up (median 43.5 months) revealed no need for reoperation for peptic ulcer disease and no mortality. CONCLUSION: We have found a high prevalence of H. pylori infection in patients with perforated peptic ulcers. An immediate and appropriate H. pylori eradication therapy for perforated peptic ulcers reduces the relapse rate after simple closure. Response rate to a triple eradication protocol was excellent in the hospital setting.

[Telematic and surgery: methods, terminology and instructions]. / Télématique et chirurgie: méthodologie, terminologie et mode d'emploi.

BACKGROUND: Telematic is the application of computer technology in modern telecommunication. Telemedicine will be of growing importance in the international collaboration in surgery. OBJECTIVE: Review of the different telematic applications for surgery and presentation of technology and tools. Practical user's guide. METHOD: Analysis of our international network of telesurgical staff meetings between 6 University Hospitals. Review of the situation of telemedicine in Switzerland and around the world. RESULTS: After performing some comparative tests we chose to work with 6 ISDN channels at the world wide standard H.320 (rate of 384 Kb/s) which is widely available in Switzerland and around the world. Technical options, market opportunities and relationship between needs and goals of telemedicine are presented on a user point of view. DISCUSSION: More than 70 telesurgical staff meetings allowed us to get an overview of this technology, in order to benefit of telemedicine applications for teaching and clinical use. Important factors are the analysis of needs and goals prior to the teleconference. CONCLUSION: Consultation, second opinion, teaching and training should be new clinical applications of telemedicine, leading to an increase of surgical quality control in Europe and in the world.

[Reflux disease: "laparoscopic therapy"]. / Refluxkrankheit: "Laparoskopische Therapie".

Laparoscopic surgery offers the patient the advantages of minimally-invasive surgery for the treatment of gastroesophageal reflux disease. Our experience with 46 laparoscopic fundoplications is favorable. The indications for surgery for patients with esophageal reflux disease remain unchanged and should not be extended. However, the good results should facilitate the decision for surgery. Several comparative studies show the safe application of laparoscopic techniques in the surgical treatment of gastroesophageal reflux disease.

[Reflux disease: laparoscopic treatment]. / Refluxkrankheit: "Laparoskopische Therapie".

Laparoscopic surgery offers the patient the advantages of a minimally-invasive surgery for the treatment of gastroesophageal reflux disease. With appropriate training the safe application of the laparoscopic fundoplication is achieved. Our experience with 46 laparoscopic fundoplications is favorable. The indications for surgery for patients with esophageal reflux disease remain unchanged and should not be extended. However, the good results should facilitate the decision for surgery. Several comparative studies show the safe application of laparoscopic techniques in the surgical treatment of gastroesophageal reflux disease.

Outcome in emotionally related living kidney donor transplantation.

BACKGROUND: The growing shortage of cadaver kidneys, the limited possibilities to expand the living related donor pool and the good results obtained in our centre with poorly matched cadaver kidneys, led us in 1991 to begin accepting highly motivated, unrelated, living kidney donors who had a strong emotional bond with the recipients. METHODS: Between 1 January 1991 and 1 January 1996, 46 potential living kidney donors and their emotionally related recipients were evaluated. Twenty-three cases were accepted for renal transplantation after thorough somatic and psychological evaluation. The mean post-transplant follow-up until 1 April 1996 was of 28 +/- 3 months. Compatible blood groups and a negative cross-match were mandatory, but no minimal HLA matching was required. RESULTS: There was a 50% drop-out rate following the initial screening. The main reasons for not performing transplantation were immunological contraindications in 39% of the cases, somatic in 30.5%, psychological in 26% and socioeconomic in 4.5%. In the accepted group of recipients, 48% (11/23) received transplants without chronic dialysis. Donor survival was 91%; two deaths unrelated to nephrectomy occurred 1 year after donation. The 2-year actuarial recipient and graft survivals were 100% and 91% respectively, compared to 99% (recipients) and 93% (grafts) in the non-HLA-identical living related kidney transplant group, and to 93% (recipients) and 83% (grafts) in the cadaver kidney transplant group. Recipient rehabilitation was completed after 4 +/- 1 months. Emotionally related donors returned to work 5 +/- 2 weeks after nephrectomy, and no donor regretted his decision, even in the case of failure. CONCLUSIONS: Kidney transplantation from emotionally related living donors represents a valuable option, allowing more patients with end-stage renal disease to avoid chronic dialysis. Recipient and graft outcomes were superior to cadaver kidney transplantation. Motivated and emotionally related donors should be allowed to donate one of their kidneys provided that they are carefully selected and thoroughly informed.

[The "pinch off" syndrome: a complication of implantable catheter systems in the subclavian vein]. / Das "pinch off"-Syndrom: eine Komplikation bei implantierbaren Kathetersystemen in die Vena subclavia.

We report the case of a 63-year-old male patient who received a subcutaneous Port-a-cath system in the right subclavian vein for administration of chemotherapy. Five weeks after successful use, flushing with NaCl 0.9% caused a painless subcutaneous swelling. Fluoroscopy confirmed a leakage below the right clavicle. The catheter was explanted and replaced by a new catheter via Seldinger technique. Two weeks later another leakage occurred and the catheter was removed definitively. Defective equipment was ruled out by the catheter producing company. The "pinch off" syndrome, a rare phenomenon of catheter compression and consecutive catheter fracture, is described, together with the diagnostic signs, the incidence and preventive measures suggested in the literature.

[The Lichtenstein inguinal hernia-plasty: a simple and complication-free technique, especially suited for ambulatory surgery]. / Die Inguinal-Hernienplastik nach Lichtenstein: Eine einfache und komplikationsarme Technik, besonders geeignet für die Tageschirurgie.

A consecutive series of 353 patients who underwent Lichtenstein mesh repair for inguinal hernia from the 1st of July 1994 to the 30th of July 1995 were studied. We analysed our indication, technique, complications, follow-up and outcome. Special consideration was given to the advantages and acceptance of day-case surgery. Our results suggest that the Lichtenstein repair should be considered as a new standard procedure, especially outside of hernia centres.

[Kidney transplantation from living donors]. / Die Nierentransplantation von Lebendspendern.

Because of the severe shortage of cadaver organs, the transplantation of living donated organs from related and also from unrelated donors has been suggested; graft survival is similar or better than with cadaver kidneys. Therefore, kidneys from living donors are a large and valuable source for transplantation which help increase the pool of organs and thus decrease the time spent waiting for organ transplantation.

[Efficacy of organ exchange rules in a 7 million population nation]. / Effizienz der Organaustauschregeln in einer 7 Mio Nation.

The suitability of organ exchange rules were analysed retrospectively in a country with a population of 7 million not connected to international organ sharing organisations following the opening of a national coordination centre 2 years previously. The results demonstrate that the sharing rules work frictionless and efficiently, and that compulsory registration of every organ donor (cadaveric and living) guarantees entire transparency of organ source and exchange, therefore preventing any illegal activity. An unacceptably high mortality rate for patients awaiting a highly urgent organ (specifically heart or liver) shows that connection to an international organ exchange organisation is desirable in this respect.

[laparoscopic cholecystectomy and acute cholecystitis--feasibility and morbidity]. / Laparoskopische Cholezystektomie und akute Cholezystitis--machbarkeit und morbidität.

This quality control study was devised to establish, wether laparoscopic cholecystectomy is recommendable for acute cholecystitis. Of 314 prospectively recorded laparoscopic cholecystectomies 59 were done for histologically proven acute cholecystitis within 3 years. 29 cases (49.2%) were converted to open cholecystectomy due to unsatisfactory exposure and recognition of anatomical structures or haemorrhage. Morbidity with laparoscopic cholecystectomy without conversion was 16.6% (5/30 patients), mortality zero. There were no common bile duct injuries. Our results show that, if the operation is performed by an experienced laparoscopic surgeon or under one's supervision, laparoscopic cholecystectomy for acute cholecystitis is safe. A low threshold for converting to open laparotomy must be observed particularly when anatomical structures are not clearly identified.

[Laparoscopic adrenalectomy in pheochromocytoma]. / Laparoskopische Adrenalektomie beim Phöchromozytom.

Standard adrenalectomy for pheochromocytoma was until recently performed via the transperitoneal open approach. The disadvantage of the open procedure is a more painful and longer recovery. With good surgical experience in laparoscopic techniques and in endocrine surgery, laparoscopic adrenalectomy can be performed safely without complications. The advantage of the laparoscopic technique is excellent vision of the operative field with magnification even of very small vessels. The first two cases of laparoscopic right adrenalectomy at our institution are described.

[Anti-reflux surgery--a boost thanks to laparoscopic techniques?]. / Antirefluxchirurgie--Aufschwung dank laparoskopischer Technik?

Laparoscopic techniques also offer the patient the advantages of minimally-invasive surgery for the treatment of reflux disease. With a appropriate training it is possible to perform laparoscopic fundoplication. Our experience with the first 16 patients is favourable. The rate of conversion to open procedure (4 from 16) and the operating times (median 176 minutes) are due to the learning curve, as known from laparoscopic cholecystectomy. The indications for surgery in patients with reflux disease remain unchanged and should not be extended. However, the good early results should facilitate the decision for surgery. The generalized use of this method should be postponed until more studies have clearly demonstrated the possible short- and long-term advantages of the laparoscopic procedure over open technique.