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

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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
swissknife spezial 06 12.06.2006 13:39 Uhr Seite 27 14.11 F.H. Hetzer 1 , D. Hahnloser 2 , D. Dindo 3 , P. Clavien 4 , N. Demartines 3 1 Viszeralsurgery, University Hospital, 8091 Zurich/CH, 2 Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich/CH, 3 Dept. of Visceral and Transplant Surgery, University Hospital of Zurich, 8091 Zurich/CH, 4 Swiss Hpb Center, Dept. Visceral and Transplant Surgery, University Hospital of Zurich, 8091 Zurich/CH When to do a percutaneous nerve evaluation (PNE) and when to do a staged implant in sacral nerve stimulation (SNS) Objective: Sacral nerve stimulation (SNS) is a successful treatment for faecal incontinence. SNS can be performed either by (PNE) requiring removal of the test electrodes and new placement of one permanent electrode or by a two stage procedure (testing with the permanent electrode and implantation of internal pulse generator). This study assesses clinical outcome and analyzes cost-effectiveness of the new two stage technique compared to the PNE technique. Methods: 36 consecutive patients underwent a two stage SNS. Outcome parameters and real costs were assessed prospectively including pre- and postoperative consultations. Results were compared with a historic group of 10 patients with PNE. Results: For the two stage procedure SNS was tested successfully in 33 patients (92%) and 31 patients (86%) were stimulated permanently. A significant reduction of incontinence symptoms was most frequently found in patients with neurogenic disorder (100% success) and in patients with sphincter defect (88%). During the first stage 8 patients (22%) reported minor complications (pain, infections and dislocations of the electrode). 8 patients (24%) had an infection, pain, or loss of effectiveness at the second stage (permanent stimulation). In comparison to PNE, only 4 out of 10 screenings (40%) with a temporary electrode received permanent stimulation (P
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