Abstracts 4. Gemeinsamer Jahreskongress der ... - SWISS KNIFE

swissknife spezial 06 12.06.2006 13:39 Uhr Seite 16
te) was circumferentially marked with radiolucent titan clips. For mesh fixation transfascial
sutures or spiral tacks were used. Follow-up was performed using radiological controls before
discharge, after 6 weeks and 6 months in prone position. Actual mesh size was measured
by an independent observer using PACS (picture archiving & communicating system). For
statistical analysis parametric tests (paired/unpaired t test) were used.
Results: A total of 30 patients (6 female, 24 male) were included in the study (23 incisional/7
ventral hernia). Median size of implanted mesh was 400cm2 (range 113-750). The overall
mesh surface decreased by 6.2% (p = 0.004, 95% CI 2.2-10.2%) after 6 weeks in comparison
to the postoperative radiological baseline measurement. In the subset of patients who
had a follow-up after 6 months (n=15) no significant changes have been observed (p = 0.82,
95% CI -9.4-7.5%). After 6 weeks shrinkage in patients with suture fixation (n=19) was 5.8%
compared to 6.8% in patients with fixation by spiral tacks (n=11).
Conclusion: In a clinical study we show a significant reduction of mesh size within the first 6
postoperative weeks after laparoscopic ventral hernia repair. No difference in mesh shrinkage
was found between suture and spiral tacks fixation after 6 weeks. Tissue ingrowth of polypropylene
mesh leads to an early mesh shrinkage with a subsequent stabilization of mesh
migration.
5.04
S. Romy 1 , M. Eisenring 2 , V. Bettschart 3 , C. Petignat 4 , P. Francioli 4 , N. Troillet 5 , S. Swiss SSI group 4
1 Chirurgie, CHCVs, 1950 Sion/CH, 2 Maladies Infectieuse, ICHV, 1950 Sion/CH, 3 Chirurgie
Générale, CHCVs, 1951 Sion/CH, 4 Médecine Préventive Hospitalière, CHUV, 1011
Lausanne/CH, 5 Maladie Infectieuse, ICHV, 1951 Sion/CH
Influence of laparoscopy on surgical site infections (SSI)
Objective: Laparoscopy provides various advantages over open surgery including a shorter
hospital stay and possibly, as suggested by studies on cholecystectomy, a lower rate of SSI.
However, in the absence of post-discharge follow-up, SSI rates might have been underestimated
in these studies, particularly in patients operated with a laparoscope who stayed for shorter
periods of time in the hospital. The present study aimed at comparing SSI rates following
operations performed by laparoscopy or open surgery in patients included in a Swiss multicentric
SSI surveillance program.
Methods: Data were prospectively gathered on 7656 operative procedures performed in 9
hospitals between March 1998 and December 2004: 3096 cholecystectomies (CCY), 2468
appendectomies (APP), and 2092 colonic surgeries (COL). A 30-day follow-up was available
for 95% of the patients. SSI rates were compared for each procedure between open operations
and those done with a laparoscope. Multivariate analysis (logistic regression) was used
to adjust for potential confounding factors such as the 3 components of the U.S. National
Nosocomial Infection Surveillance (NNIS) index (contamination class, ASA score, duration of
the operation), the age, the gender, any re-intervention done for a non infectious complication,
and the hospital.
Results: Laparoscopes were used in 14.9% of COL, 42.6% of APP, and 85.6 of CCY. SSI rates
were 20.8%, 7.2% and 2.6% respectively. 19%, 66%, and 45% of SSI were diagnosed postdischarge
respectively. In univariate analysis, the use of a laparoscope was associated with
a risk reduction of 50% for COL (OR: 0.5; [95%CI: 0.36-0.69]), 32% for APP (0.68 [0.50-
0.92]), and 78% for CCY (0.22 [0.14-0.34]). In multivariate analysis, laparoscopy remained
independently associated with lower rates of SSI in COL (0.43 [0.29-0.63]), APP (0.61 [0.43-
0.87], and CCY (0.27 [0.16-0.43]).
Conclusion: The use of a laparoscope is independently associated with lower SSI rates for
cholecystectomy, appendectomy, and colon surgery. This is not related to the shorter hospital
stay observed after laparoscopic procedures, but rather due to a real „protective” effect of
laparoscopy against SSI.
5.05
R.S. Jost 1 , C. Zollikofer 2 , E. Schoch 2 , B. Brunner 3 , M. Decurtins 4 , R. Jost 3
1 Surgery, Kantonsspital Winterthur, 8401 Winterthur/CH, 2 Department of Radiology, Kantonsspital,
Winterthur/CH, 3 Internal Medicine, Gastroenterology, Kantonsspital Winterthur, Winterthur/CH,
4 Chirurgische Klinik, Kantonsspital, 8401 Winterthur/CH
Acute left sided large bowel obstruction – influence of preoperative stenting on outcome and
costs
Objective: To demonstrate effectiveness and the influence on costs of preoperative stent placement
in acute obstruction of the left sided colon
Methods: In this retrospective study 44 consecutive patients (18 f, 26 m) with clinical and
radiological signs of severe acute left-sided colonic obstruction due to colorectal malignancy
distal to the splenic flexure were treated by preoperative stenting and secondary operation
(Stent group, SG n= 26) or by direct surgery only (Conventional group, CG n = 18). Both
groups were comparable in respect of age and disease. Self expandable enteric Wallstents
were implanted under combined fluoroscopic and endoscopic guidance. The costs generated
for every individual patient were calculated for the following parameters: Total hospital
stay (general unit and ICU), colonoscopy, stent placement and surgery.
Results: The SG had significantly more primary anastomoses (SG: 88%; CG 44%), a lower
rate of colostomy (SG: 12 %; CG: 56 %), fewer reinterventions (SG: 1,1; CG 1,8 per case) and
lower postoperative morbidity, resulting in shorter stay in the ICU and total hospital days. The
overall costs per case were significantly lower in the SG compared to the CG (USD 36`188
vs. 44`298; reduction 18%).
Conclusion: Stent placement in acute left sided colonic obstruction allows an elective onestage
operation in most cases. Compared to conventionally treated patients hospitalisation
time and rate of temporary or permanent colostomy are greatly reduced, thus leading to lower
overall costs per patient.
5.06
A. Wistop 1 , M.O. Guenin 2 , S.A. Baierlein 2 , R. Peterli 2 , B. Kern 2 , C. Ackermann 2 , M. von Flüe 2
1 Department of Surgery, St.Claraspital, 4016 Basel/CH, 2 Surgery, St.Claraspital, 4016
Basel/CH
Latero-terminale Anastomose (LTA) in der laparoskopischen Kolonchirurgie: Morbidität und
funktionelle Resultate
Objective: Die laparoskopische Kolonresektion hat in den letzten Jahren vor allem in der chirurgischen
Therapie der Divertikulitis stark an Bedeutung zugenommen. Dabei ist die terminoterminale
Anastomosentechnik mittels Stapler eine Möglichkeit zur Rekonstruktion. Wir prüf-
16 swiss knife 2006; special edition
ten die 30-Tages-Morbidität und funktionellen Resultate nach LTA auch hinsichtlich des subjektiven
Langzeitresultates. Für die LTA spricht eine leichte Adaptation des Kaliberunterschiedes,
eine gute antimesenteriale Durchblutung und das seltene Vorhandensein von
Divertikeln in diesem Darmbereich. Dies könnte zur Verminderung der
Anastomoseninsuffizienzrate beitragen.
Methods: Die prospektiven Daten von 96 Patienten mit Sigma- bzw. linksseitiger
Kolondivertikulitis, welche sich einer laparoskopischen Kolonresektion unterzogen haben
(09/2003-12/2005), wurden hinsichtlich der 30-Tages-Morbidität und funktioneller
Resultate analysiert. Die Resektion beinhaltet eine zentrale Durchtrennung der Mesenterica
inf. Gefässe. Bei allen Patienten erfolgte die kolorektale Anastomose mittels Stapler in einer
latero-terminalen Technik unterhalb des Promontoriums. Das Follow up (90%) wurde mittels
standardisiertem Fragebogen durchgeführt.
Results: Das Durchschnittsalter lag bei 60 Jahren (41-72). Durchgeführt wurden
Anteriorresektionen (83%), Sigmaresektionen (12%) und linksseitige Hemikolektomien (5%).
Die Konversionsrate betrug 4%. Die 30-Tages-Morbidität lag bei 13%, die Mortalitätsrate bei
0%. Eine operationsbedürftige Komplikation (Trokarhernie) hat sich bei 1% entwickelt. Eine
Insuffizienz der LTA ist nicht aufgetreten. Zu Spätkomplikationen kam es bei 8% der Patienten,
wobei nur eine operative Revision aufgrund einer Narbenhernie notwendig war. Im
Langzeitverlauf wurde eine symptomfreie Stenose im Anastomosenbereich dilatiert. 84% der
Patienten waren mit dem gesamten Verlauf sehr zufrieden, nur 11% fühlten sich durch veränderte
Stuhlgewohnheiten gestört.
Conclusion: Im Rahmen laparoskopischer Kolonresektionen bei Kolondivertikulitis zeigt die
LTA bei einer geringen perioperativen Morbidität und einer Mortalitäts- und
Anastomoseninsuffizienzrate von 0% zudem sehr gute funktionelle Resultate.
5.07
B. Roche 1 , J. Robert-yap 2 , G. Zufferey 3 , R. Chautems 4
1 Chirurgie, Unité de Procotlogy HUG, 1211 Geneve 14/CH, 2 Chirurgie, hug procotologie, 1211
Geneve 14/CH, 3 Chirurgie, Hôpital Zone de Nyon, Nyon/CH, 4 Chirurgie, Kantonspital Soloturn,
Soloturn/CH
Is there still a place for surgical treatment of perineal fistulas in Crohn’s disease?
Objective: Many new conservative treatments are described concerning fistulas in Crohn’s
disease, However, in some resistant cases surgical treatment can be advocated. The purpose
of this paper is to review cases where conservative and surgical therapies were used to
treat perineal fistulas in Crohn’s disease and evaluate the outcome.
Methods: We reviewed the cases of 672 patients from our clinic who were treated from 1994
to 2004 for anal fistulae, of whom 59 (8.8%) had Crohn’s disease. In these 59 Crohn’s
patients, the following treatments were used: fistulotomy 10.2%, advancing flap 71.2% and
advancing flap with autologous glue sealant 18.6%.
Results: The mean age of the Crohn’s patients was 34 years. The male-to-female ratio was
found to be 0.31 in Crohn’s disease. On average, the Crohn’s patients had twice as many fistulae
and they were generally more complex. The proportion of recto-vaginal fistulae was higher
in Crohn’s patients with 14.2% versus 2% in the average population. The patients who
were treated with surgery failed conservative management. However, despite this fact, the
overall success in attempting conservative therapy first then falling back on surgery as
second line treatment shows an overall success rate of 59.5%, leaving these patients free of
symptoms.
Conclusion: One must always be aware that early success may be followed by later recurrence,
so scrupulous follow-up is necessary. The advancing flap technique is used in many
cases to preserve the anal profile and to maintain continence. Thus, surgical therapy should
be performed only in cases of failed conservative treatment and the appropriate technique
should be based on each individual case. Even if there is a chance of post-operative recurrence,
the overall success rate and the potentially long intervals without perineal sepsis are a
benefit to the patient in their own right. This symptom relief offered by surgery maintains a still
vital role in the management of perineal fistulas in Crohn’s disease.
5.08
B. Huettenmoser, U. Gögus, I. Reilly, W. Schweizer
Chirurgie, Kantonsspital, 8200 Schaffhausen/CH
Longtime results after Stoppa operation for the treatment of primary and recurrent inguinal
and femoral hernias
Objective: Aim of the study was to evaluate longtime results after Stoppa inguinal hernia
repair. In 1973 René Stoppa introduced a new operation technique for the treatment of inguinal
and femoral hernias. By implanting a preperitoneal mesh through one midline incision,
inguinal and femoral hernia can be treated at once on both sides.
Methods: All our patients operated by Stoppa’s technique from January 1999 to May 2005
were included in the study. Out of all 311 operated patients, 245 could be reached by phone
and 33 of those were then clinically examined. The mean time after operation was 27.2
months (1-72).
Results: The overall recurrence rate was 0.8%. In 7.8% patients we found hydroceles, 90% of
which were confirmed by ultrasound, but only one patient wanted to be treated. 54% of the
patients had no pain at all, 30% reported minimal tension or pain, tension of the abdominal
wall or sensitive testicles. 14% of the patients had slight complaints as inguinal or scrotal pain.
2% of all patients had major complications such as hernia recurrence, heavy inguinal, abdominal
or scrotal pain.
Conclusion: The bilateral preperitoneal implantation of Mersilenemesh according to René
Stoppa’s technique has a low recurrence and complication rate, which makes it a valuable
option for unilateral techniques in primary hernias and a preferred technique for recurrent hernia
repair.
5.09
W. Steinke 1 , F. Allemann 2
1 Chirurgische Abteilung, Kantonsspital Schaffhausen, 8209 Schaffhausen/CH, 2 Chirurgische
Klinik, Kantonsspital Frauenfeld, 8500 Frauenfeld/CH
Future professional education in laparoscopic surgery as seen by the chief surgeons in
Switzerland – A representative survey
Objective: Professional education in laparoscopic surgery is a challenge for Surgical
Societies any-where: it requires complex training set-ups, exquisite surgical and didactical