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

swissknife spezial 06 12.06.2006 13:39 Uhr Seite 26
14.06
L. Flemming 1 , R. Bühlmann 2 , R. Schlumpf 3
1 Allgemeine Chirurgie, Kantonsspital Aarau, 5001 Aarau/CH, 2 Klinik für Chirurgie, Kantonsspital
Aarau AG, 5001 Aarau/CH, 3 Klinik für Chirurgie, Kantonsspital Aarau AG, Aarau/CH
The asymptomatic pneumoperitoneum a freak of nature
Objective: The pneumoperitoneum indicates in about 90% a perforated abdominal viscus
that requires emergency surgery. In about 10% typical clinical signs like peritonitis, strong
abdominal pain and leukocytosis are absent and the pneumoperitoneum does not require an
emergent surgical treatment. Abdominal tenderness can be the only clinical sign of the „spontaneous”
pneumoperitoneum. The spectrum of causes of this rare clinical condition include
abdominal, thoracic, gynaecological sources and the postoperative state. But sometimes the
source keeps hidden.
Methods: Case report: a 71 years old male was admitted to a pulmonary rehabilitation hospital
due to his exacerbated COPD with pulmonary emphysema. He was in a reduced general
condition without any history of abdominal pain nor any current clinical signs of abdominal
disorders. The chest radiography showed free abdominal air below both diaphragms, but
blood examination was uneventful including the inflammatory values. The patient was referred
to our emergency unit for further diagnostic. Gastroscopy, thoracic and abdominal computertomography
didn’t show any pathology including a perforation of the abdominal viscus
and pneumomediastinum. The 48 hours observation was uneventful, the chest radiography
was unchanged and the patient was referred back to the rehabilitation hospital. Chest radiography
a few weeks later didn’t show free abdominal air.
Results: Beside postoperative state, known sources of an asymptomatic pneumoperitoneum
are pneumatosis cystoides intestinalis, peritoneal dialysis, PEG tube placement, diagnostic
and therapeutic colonoscopy, mechanical ventilation, cardiopulmonary resuscitation, gynaecological
examinations and as well the perforation of an emphysematic bulla. In the abscence
of a pneumomediastinum even this source is most unlikely in our case.
Conclusion: The pneumoperitoneum is usually an absolute indication of emergency surgery.
But in some rare cases the pneumoperitoneum is asymptomatic and doesn’t require any
treatment. As in our case, it might be a freak of nature.
14.07
R.E. Vandoni 1 , A. Krpo 2 , P. Gertsch 3
1 Surgery, Ospedale San Giovanni, 6500 Bellinzona/CH, 2 Anaesthsiology, Ospedale San
Giovanni, Bellinzona/CH, 3 Chirurgia, Ospedale San Giovanni, 6500 Bellinzona/CH
Ultrasound activated blade vs clamp division for hepatic transection. Randomised prospective
study
Objective: Excessive intraoperative blood loss is a major determinant of adverse outcome in
hepatectomies. To minimize intraoperative bleeding, controlled low central venous pressure
may be combined with inflow occlusion such as the Pringle manoeuvre. Transection of the
hepatic parenchyma may be performed in many ways. We evaluate two different techniques.
Methods: Patients submitted to hepatectomy were randomised in two groups. Transection of
the hepatic parenchyma was performed either by clamp division and electrocautery (Group
I) or by ultrasonic activated blade (ultracision ® blade) (Group II). We analyzed the duration of
hepatic resection, blood loss during the resection, the cut surface and the weight of the resected
liver and the demographic data. The same surgical team operated on all patients under
controlled low central venous pressure. Inflow occlusion was used only when blood loss was
over 300 mL during resection. Uni- and multivariate analysis were performed.
Results: Fifty-eight consecutive patients (24F/34M, age 63) were randomised (27 in Group I,
31 in Group II). The two groups were similar in age, sex distribution and type of hepatectomy
(minor or major). There was no statistically significant difference between groups, in the proportion
of inflow occlusion applied, in the duration of resection (82±47 min vs 100±46 min,
p=0.16), in the blood loss (319±300 mL vs 599±720 mL, p=0.06) in the cut surface
(74.5±40 cm2 vs 88±51 cm2, p=0.26) and the weight (425±348 g vs 394±405 g, p=0.75)
of the resected liver.
Conclusion: These two techniques of hepatic transection seem equivalent in terms of safety
and time.
14.08
O.J. Wagner 1 , R. Inglin 1 , R. Weimann 2 , S. Bisch-Knaden 1 , D. Candinas 3 , B. Egger 4
1 Dpt. of Viszeral and Transplantation Surgery, Inselspital, University of Bern, 3010 Bern/CH,
2 Pathologie, University, 3010 Bern/CH, 3 Vchk, Inselspital, Bern/CH, 4 Department of Visceral
and Transplantation Surgery, Inselspital, University of Bern, 3010 Bern/CH
Neoadjuvant short-term radiotherapy impressively impairs rectal mucosal architecture and
is a major risk factor for leakage of low rectal anastomoses
Objective: Randomized controlled multicenter trials revealed that patients with advanced rectal
cancer undergoing low anterior resection (LAR) and total mesorectal excision (TME) benefit
from neoadjuvant preoperative short-term-radiotherapy (STRT) (5x5Gy, 5 days) in terms of
local recurrence rate and prolonged survival without serious adverse effects. In contrast to
this we observed in our patient collective with low rectal cancer (LRC) undergoing STRT prior
to LAR/TME a high anastomotic leakage rate (ALR).
Methods: In the past two years 64 patients with rectal cancer were treated at our institution
and all received endosonographic staging. 45 of them underwent LAR/TME, of whom 20 had
low rectal cancer (distal tumor border < 4cm above the upper anal verge; UAV). 20 of them
had LRC (distal tumor border < 4cm above the UAV). In this group (n=20) asymptomatic
patients (no bleeding or stenosis) and patients with no need for downstaging of the tumor
underwent STRT (total dose of 25Gy in 5 fractions during 5 days) (n=6). All other patients
underwent either immediate LAR/TME (n=11) or operation after a 4 week course of neoadjuvant
chemo-radiotherapy (LTRCT) (n=3). Anastomotic leakage was verified by computed
tomography or by contrast agent enema. Distal (rectal) margins of the resected specimen
were evaluated by morphometry and immunohistochemistry (KI-67: proliferation marker).
Results: Overall ALR in patients with LRC was 15% (3/20). In patients with STRT ALR was
50% (3/6), in the group without STRT and LTRCT 0% (0/14) (p