Magnetic resonance spectroscopy for assessing myocardial rejection in the transplanted rat heart.

Traditionally, detection of heart rejection after heart transplantation is based on histologic grading of endomyocardial biopsy specimens. The value of magnetic resonance spectroscopy for determining heart rejection was assessed in rejecting and nonrejecting isografts and allografts using energy-rich phosphate spectroscopy. In 46 rats a heterotopic abdominal heart transplantation was performed, and animals were divided into the following groups: six isografts (no rejection), five untreated allografts (severe rejection), and 35 immunosuppressed allografts (mild to moderate rejection). One week after transplantation magnetic resonance spectroscopy was performed, and data were correlated to histologic findings (rejection grades according to Stanford and the New International Working Formulation classifications and relative volume of viable myocardium). Magnetic resonance spectroscopy allows detection of moderate to severe rejection with significant alterations in the energy-rich phosphates such as a decrease in the ratio of phosphocreatine/inorganic phosphate, phosphomonoester/inorganic phosphate, and beta-adenosine triphosphate/inorganic phosphate. A significant correlation was found between spectroscopic changes (phosphocreatine/inorganic phosphate) and histologic rejection (correlation coefficient r = 0.47, p < 0.005) and/or the amount of relative volume of viable myocardium and phosphocreatine/inorganic phosphate (r = 0.58) or beta-adenosine triphosphate/inorganic phosphate (r = 0.63), respectively. In conclusion magnetic resonance spectroscopy permits detection of moderate to severe degrees of heart rejection with a sensitivity of 85% and a specificity of 61%. Changes in the energy-rich phosphates correlate with the histologic grading of heart rejection and the relative volume of viable myocardium. Magnetic resonance spectroscopy appeared to be a valid technique for detecting myocardial rejection after heart transplantation in the reported experimental model.

Randomized controlled trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice repair.

BACKGROUND: There is a scarcity of data on long-term results after laparoscopic hernia repair. Herein we report on the outcome of a group of patients who were followed up for 5 years in a multicenter study on hernia repair. METHODS: A total of 100 patients with 127 hernias were randomized to undergo either transabdominal preperitoneal (TAPP) or Shouldice hernia repair. Follow-up was by clinical examination and standardized questionnaire. RESULTS: Of the 100 patients who underwent surgery, 84 were available for follow-up at 5 years. The TAPP procedure was less painful than the Shouldice repair, with fewer patients receiving narcotic analgesics. The median time to return to 100% activity was shorter in the laparoscopic group (21 days) than in the Shouldice group (40 days). Up to 60 months after the operation, the complication rate was lower in laparoscopically repaired hernias (19/66) than in the open group (25/61). There were two recurrences (3.9%) in the TAPP group and five in the Shouldice group (10.2%). CONCLUSION: The TAPP hernia repair yields comparable or better results than Shouldice herniorrhaphy in terms of postoperative pain, recovery, and recurrence rate.

[Morbidity of Z-plasty in the treatment of pilonidal sinus]. / Die Morbidität der Z-Plastik in der Behandlung des Pilonidalsinus.

21 patients were followed up on an average of 28 months following excision of pilonidal sinus and Z-plasty. There were 2 recurrences (10%), 3 hypertrophic scars (14%) and hypaesthesia of the skin flaps in almost every patient. 2 out of 3 patients (67%) were satisfied with the results. 5 suffer from the cosmetic appearance, 5 from pruritus, 3 (14%) have problems with clothing. About 1/3 experience discomfort when sitting and sporting. This morbidity causes us to recommend Z-plasty only in cases of a recurrence with strong discomfort or frequent recurrences.

[Long-term results following surgery of varicose veins]. / Langzeitresultate nach Varicenoperation.

In a long-term follow-up after operation for primary varicose vein disease, patients were revisited 5, 10 and 15 years after their operation, in an attempt to define the goal of the treatment and the result. The results were analyzed as well as those factors which had a significant influence on the findings at assessment. The long-term results were good with respect to the patient's self-judgement and relative to improvement of trophic disturbances, especially of venous ulceration, however recurrent superficial varicose veins increase significantly with increasing follow-up time. The outstanding role of incompetent communicating veins is discussed with respect to trophic disturbances and recurrent varicose veins.

On-line determination and control of fat content in batches of beef trimmings by NIR imaging spectroscopy.

An NIR imaging scanner was calibrated for on-line determination of the fat content of beef trimmings. A good calibration model was obtained for fat in intact beef (R=0.98, RMSECV=3.0%). The developed model could be used on single pixels to get an image of the fat distribution, or on the average spectrum from each trimming/portion of trimmings passing under the scanner. The fat model gave a rather high prediction error (RMSEP=8.7%) and a correlation of 0.84 when applied to 45 single trimmings with average fat content ranging from 1.6 to 49.3% fat. Test measurements on streams of trimmings making up batches varying from 10 to 24 kg gave a much lower prediction error (RMSEP=1.33%). Simulations based on true measurements indicate that the RMSEP decreases with increasing batch size and, for the present case, reached about 0.6% for 100 kg batches. The NIR scanner was tested on six batches of intact trimmings varying from 145 to 210 kg and gave similar fat estimates as an established microwave system obtained on the ground batches. The proven concept should be applicable to on-line estimation of fat in trimmings in order to determine the batch fat content and also to control the production of batches to different target fat levels. A possible requirement for the concept to work properly is that the trimming or layer of trimmings on the belt is not too thick. In this study maximum thickness was about 8 cm. Thicker trimmings might be measured, but careful hardware adjustments are then required.

[Obstruction ileus caused by mushrooms]. / Obstruktionsileus durch Pilze.

Since 1982 we have performed surgery in 2 cases of obstruction ileus caused by fungi. Both patients had stenosis of the gut, due to adhesions and Crohn's disease respectively. Unless carefully chewed, mushrooms keep their shape and almost their size in the bowel, and can thus become jammed in a stenosis and cause ileus. High risk patients should be advised to avoid eating mushrooms or else to chew them very carefully.

[Laparoscopic suturing of a perforated gastroduodenal ulcer]. / Laparoskopische Ubernähung eines perforierten gastroduodenalen Ulkus.

The mortality rate for perforated peptic ulcer ranges from 10 to 30%. Age above 70 years, preoperative shock, operation more than 24 hours from the time of acute onset, and poorly controlled concurrent illness are considered to be risk factors. Individuals with any of these features are deemed unfit for definitive surgery and should undergo simple omental patch suture alone. This case report details the laparoscopic management of an 86-year-old female with a ruptured duodenal peptic ulcer who was receiving corticosteroids and a non-steroidal antiinflammatory drug. Laparoscopy is of diagnostic value and permits efficient cleaning of the abdominal cavity. Provided the laparoscopic principles of management are essentially the same as those adhered to during open surgery, the minimally invasive procedure may help to reduce postoperative morbidity and mortality.

[Does laparoscopic lysis of adhesions make sense?]. / Ist die laparoskopische Adhäsiolyse sinnvoll?

Between May 1989 and December 1991 23 patients were operated on laparoscopically for symptomatic peritoneal adhesions. 19 were followed up by telephone using a standardized questionnaire an average of 18.3 months post-operatively (range 5-36 months). 12 patients were totally painfree, 3 complained of slight pain, 2 patients of fairly severe and 2 of severe pain. 15 patients considered the outcome of the operation to be good or fairly good and 18 said they would undergo the same operation in similar circumstances. We therefore recommend laparoscopic adhesiolysis in cases of acute or chronic abdominal pain, provided other causes of abdominal discomfort have been ruled out.

[Does laparoscopy influence the treatment of choledocholithiasis?]. / Beeinflusst die Laparoskopie die Behandlung der Choledocholithiasis?

Operative common bile duct exploration, performed in conjunction with cholecystectomy, used to be considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. The advent of laparoscopic cholecystectomy (LC) has affected the management of common bile duct stones. More emphasis is placed on preoperative intravenous cholangiography (IVC) and endoscopic retrograde cholangiography (ERC) with endoscopic papillotomy (EP) either just before or soon after laparoscopic surgery. This involves the patient in an additional procedure with its associated risks. Single-stage treatment of biliary lithiasis, i.e. LC and laparoscopic common bile duct exploration (LCDE) appears preferable to two-stage treatment, especially when the ampulla of Vater can be preserved. 550 consecutive patients with LC are reviewed. IVC with tomography was performed in 341 of these patients without complications and with a sensitivity of 75% and a specificity of 99%. The procedure failed in 5.6% due to poor quality imaging, and was contraindicated in 21 patients. With increasing laparoscopic experience, intraoperative cholangiography (IOC) was adopted and has been used routinely since November 1992. IOC was successful in 204 of 209 attempts (97.6%) with a sensitivity of 95% and a specificity of 100%. The mean operation time for IOC was 10 minutes. Unsuspected bile duct stones were found in 6% of instances. IOC demonstrated one choledochotomy (0.18% of all LC), thus preventing transsection of the duct. 47 patients (8.5%) had common duct stones. 29 (62%) were treated by ERC and EP, while 18 (38%) underwent LCDE. Successful clearance was achieved endoscopically in 94% and laparoscopically in 82% of the attempts.(ABSTRACT TRUNCATED AT 250 WORDS)

An evaluation of laparoscopic adhesiolysis in patients with chronic abdominal pain.

The purpose of this prospective study was to determine whether laparoscopic adhesiolysis ameliorates chronic abdominal pain in patients with abdominal adhesions. Forty-five patients with chronic abdominal pain lasting for more than 6 months but with no abnormal findings other than adhesions found at laparoscopy underwent laparoscopic adhesiolysis. Thirty-six patients (80%) were available for follow-up after a median time interval of 10 months (range: 6-36 months). Seventeen patients (47.2%) were free from abdominal pain and 13 patients (36.1%) reported significant amelioration of their pain. Six (16.6%) patients had no amelioration. Twenty-nine patients (80.6%) judged the outcome of the operation to be good or beneficial and 35 (97.2%) said that they would undergo the operation a second time if that were necessary. Laparoscopy is an effective tool for the evaluation of patients with chronic abdominal pain, and laparoscopic adhesiolysis cures or ameliorates chronic abdominal pain in more than 80% of patients.

[Simultaneous laparoscopic therapy of cholecysto- and choledocholithiasis. An analysis of results]. / Die einzeitige laparoskopische Therapie der Cholezysto- und Choledocholithiasis. Eine Resultatanalyse.

INTRODUCTION: With the advent of laparoscopic cholecystectomy, ERCP has gained importance in the treatment of choledocholithiasis. Laparoscopic cholecystectomy with intraoperative cholangiography and common bile duct surgery allows diagnosis and treatment of cholecystolithiasis and choledocholithiasis in a single procedure. PATIENTS AND METHODS: Laparoscopic treatment of choledocholithiasis was evaluated in 99 consecutive patients with choledocholithiasis. 28 patients underwent successful preoperative ERCP. Of the patients with intraoperative confirmation of choledocholithiasis, removal was attempted by a transcystic approach in 36 and 23 underwent choledochotomy. 24 patients with a high operative risk underwent postoperative ERCP. RESULTS: The transcystic approach was successful in 72.2%. Choledochotomy was successful in 91.3%, yielding a combined success rate of 80%, 3.4% had local complications and 8.4% had other complications (complication rate 11.8%), 20.3% of the patients underwent ERCP after failed laparoscopic procedures. One patient had a laparoscopic redo. There was no mortality and no conversion to open surgery. CONCLUSION: ERCP and laparoscopic common bile duct surgery are complementary, efficient and safe modalities of treatment for choledocholithiasis. Choice of procedure is influenced by the surgeon's experience and institutional infrastructure, and the individual patient.

[Laparoscopic intestinal surgery]. / Laparoskopische Darmchirurgie.

The objective of the present study was to demonstrate the feasibility of laparoscopic bowel surgery. From June 1990 to September 1993 14 small bowel and 15 colon operations were performed laparoscopically in the surgical department of Aarberg Hospital. The results have been analyzed retrospectively. The indication for all small bowel operations was intestinal obstruction. Adhesiolysis, hernia repair and resections were performed either by laparoscopy or by laparoscopically assisted surgery. There were no complications. Laparoscopy therefore has proven to be a good method for treating intestinal obstruction of various origin. 11 colon resections were performed without anastomotic leakage. There were two conversions to laparotomy. Three complications occurred but resolved spontaneously. Two patients died from causes unrelated to the laparoscopic procedure. Our results demonstrate that laparoscopic resections of the colon are feasible. Further evaluation is needed to assess their clinical value.

Laparoscopic stapler appendectomy. A prospective study of 267 consecutive cases.

BACKGROUND: The value of laparoscopic appendectomy remains controversial. Therefore, we investigated the accuracy of diagnostic laparoscopy in detecting acute appendicitis and tested the applicability and safety of stapling appendectomy as a routine procedure. METHODS: Data from 267 consecutive patients with suspicion of acute appendicitis were recorded prospectively. RESULTS: Histopathological examination revealed nonperforated and perforated appendicitis in 63.3% and 13.1%, respectively, and no inflammation in 10.8%. Other pathological findings were observed in 12.7%. Diagnostic laparoscopy detected appendicitis with a sensitivity and specificity of 95.6% and 96.6%, respectively; the positive and negative predictive value were 99.5% and 74.3%, respectively. Morbidity was 10.2% in total and 40% for perforated appendicitis. Planned laparoscopic reexploration reduced morbidity by 23.4% in patients with perforated appendicitis and substantial peritonitis. Mortality was 0.4%. CONCLUSIONS: Laparoscopy improves diagnostic accuracy for acute appendicitis and laparoscopic stapling appendectomy is a safe and efficient procedure for all forms of appendicitis.

Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC).

BACKGROUND: This article reports the results of a multicenter prospective audit of totally extraperitoneal (TEP) inguinal hernia repair conducted by the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC) from May 1995 to August 1996. METHODS: At 29 Swiss centers 1,605 inguinal hernia repairs were performed in 1,186 patients. Half of the repairs were performed by operators whose experience consisted of fewer than 51 procedures. Patients were followed up for 1 year. RESULTS: Bilateral repairs were performed in 35% of the patients, and 15% of all repairs were for recurrent hernia. Conversion rates to the transabdominal preperitoneal (TAPP) technique and open surgery were 1.8% and 1.6%, respectively. Main postoperative complications were hematoma and urinary retention. At 3 months, seroma was more frequent with slit prosthesis. The recurrence rate was 0.6% at 3 months and 1.6% at 1 year, not depending on the type of implant. The rate for recurrent hernias did not differ from that for primary repairs. CONCLUSIONS: Total extraperitoneal (TEP) repair can be performed with low morbidity and a high level of patient satisfaction. The effects of the learning curve are not to be neglected. The 1-year recurrence rate is 1.6%. Published data on TEP suggest that late recurrences may be less frequent than after open repair.

Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy. Early results.

BACKGROUND: In February 1993 a prospective randomized multicenter trial was initiated to compare laparoscopic transabdominal preperitoneal hernioplasty to Shouldice herniorrhaphy as performed by surgeons of nonspecialized clinics. METHODS: Until January 1994, 87 patients with 108 hernias took part in the trial (43 Shouldice and 44 laparoscopic repairs). RESULTS: The laparoscopic procedure took significantly longer than did the open operation but caused less pain as measured by pain analogue score and consumption of paracetamol and narcotics. The postoperative complication rate was 26% in the open and 16% in the laparoscopic group. The patients in the laparoscopic group were discharged earlier and their convalescence was shorter than after open hernia repair. There has been one early recurrence in the laparoscopic and two in the open group to date with a mean follow-up of 201 days. CONCLUSIONS: Laparoscopic hernia repair causes less pain than the conventional operation and enables the patient to return to full work and usual activities earlier. The recurrence rate will not be known for 5 years.