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

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swissknife spezial 06 12.06.2006 13:39 Uhr Seite 34 16.14 R. Marti1 , I. Schwegler2 , T. Obeid3 , L. Gürke4 , P. Stierli5 1 2 Chirurgische Klinik, Kantonsspital Aarau AG, 5001 Aarau/CH, Gefässchirurgie, Kantonsspital Aarau, 5000 Aarau/CH, 3Gefässchirurgie, Kantonsspital, 5001 Aarau/CH, 4Gefäss chirurgie, Universitätsspital Basel, Basel/CH, 5Gefässchirurgie, Kantonsspital Aarau, Aarau/CH Patchinfekt nach Carotis-TEA. Eine seltene Komplikation. Ein Fall mit fatalen Folgen Objective: Einleitung: Anhand einer Fallbeschreibung wird die seltene Komplikation des Patchinfektes nach Carotis-TEA diskutiert. Methods: Fallbeschreibung Results: Fallbericht: 3 Jahre nach einer Carotis-TEA mit Dacronpatch-Verschluss tritt bei einer 50-jährigen Patientin ein Eiteraustritt über die Narbe auf. Bei Verdacht auf einen Patchinfekt erfolgt die Rekonstruktion der Bifurkation mittels Veneninterponat. In sämtlichen entnommenen Proben ist kein Bakterienwachstum nachweisbar. In der Folge antibiotische Therapie mit Ciprofloxacin. 2 Monate später erneute Sekretion aus der Narbe. Im Duplex Nachweis eines Flüssigkeitssaum um das Interponat. Es erfolgt eine antibiotische Therapie mit Vancomycin für 2 Wochen und Zyvoxid für weitere 4 Wochen. Nach Abschluss der Therapie Persistenz der ödematösen Verquellung des U mgebungsgewebe und hochgradige Stenose des Interponates (Duplex/MRI). Rehospitalisation nach einem weiteren Monat mit Kreislaufschock bei anämisierender GI-Blutung unter OAK. Bei Eintritt Hyposensibilität der rechten Gesichtshälfte. Im Duplex nach Revertierung der OAK Nachweis eines thrombotischen Verschlusses der Carotisgabel. Im CT Mediainfarkt. Bei progredientem Hirnödem erfolgte die Kraniotomie. Die Patientin konnte nach 3 Wochen mit einer Hemiparese links in die Rehab entlassen werden. Bei erneutem Verdacht auf einen low-grade Infekt Therapieversuch mit Vancomycin. Bei Ausbleiben einer Besserung der Infektwerte Beginn mit einer Steroidtherapie bei Verdacht auf eine Vasculitis. Unter einer Dosierung mit 50 mg Prednison deutliche Besserung des Befundes. Conclusion: Schlussfolgerung:. Der Patchinfekt ist eine seltene Komplikation nach Carotis- TEA. In der Literatur wird die Inzidenz mit unter 1% beschrieben. Das therapeutische Konzept umfasst das lokale Debridement mit Excision des infizierten Arteriensegmentes und Ersatz mittels Veneninterponat begleitet von einer Langzeitantibiotikatherapie. 16.15 P.A. Stalder1 , J.C. van den Berg2 , R. Rosso3 1 2 Vascular Surgery, Ospedale Regionale Lugano, 6900 Lugano/CH, Radiology, Ospedale Regionale Lugano, Lugano/CH, 3Vascular Surgery, Ospedale Regionale Lugano, Lugano/CH Endovascular treatment of isolated common iliac artery aneurysm using a bifurcated stentgraft: a potential pitfall Objective: Endovascular repair of isolated common iliac artery (CIA) aneurysm is feasible when specific anatomical criteria are met. We describe a potential pitfall of endovascular iliac artery aneurysm repair. Methods: A 78-year old man was referred with an incidental finding of a right 9.7cm CIA aneurysm and a mild dilatation of the abdominal aorta. As the aneurysm had no proximal neck, it was decided to treat the patient with a bifurcated stent. The aneurysm extended to the right iliac bifurcation, which necessitated an embolization of the ipsilateral internal iliac artery. Afterwards the main body of a bifurcated stent was inserted and deployed. After ipsilateral iliac extension canulation of the contralateral stump was attempted. The gate of the contralateral limb was at the level of a focal narrowing of the abdominal aorta, not fully deployed. Canulation from a left contralateral approach was impossible. With a cross-over technique a guidewire was passed into the left iliac artery. The contralateral limb was inserted, but could not pass beyond the local narrowing of the distal aorta. Kissing balloon-angioplasty of the aorta was performed. After this the procedure was uneventful. Results: Endovascualr treatment of isolated CIA aneurysms is feasible. Various approaches can be employed, ranging from the use of covered stents placed percutaneously, to the use of iliac extensions or modular stents. Covered stents and iliac extensions from modular stent systems can only be used in cases with sufficient proximal and distal neck. In the absence of a proximal neck, the stent has to be extended into the distal abdominal aorta. When using a bifurcated stent the absence of a large diameter distal abdominal aorta may cause a failure of deployment of the contralateral limb to its full diameter, thus hampering the canulation of the stump. When planning an endovascular procedure, this potential pitfall must be taken into account. When canulation of the contralateral leg is impossible, endovascular conversion into an aorto-uni-iliac stent should be considered as a bailout procedure, prior to conversion to open surgery. Conclusion: Endovascular treatment of an isolated CIA aneurysm using a bifurcated stent system is feasible. A potential pitfall exists if the distal abdominal aorta is not dilated. 16.16 B.K. Wölnerhanssen 1 , A.L. Jacob 2 , T. Wolff 3 , L. Gürke 4 , T. Eugster 5 1 Surgery, University Hospital Basel, 4056 Basel/CH, 2 Interventional Radiology, University Hospital Basel, 4056 Basel/CH, 3 Vascular Surgery, University Hospital Basel, Basel/CH, 4 Gefässchirurgie, Universitätsspital Basel, Basel/CH, 5 Gefässchirurgie, Universitätsspital Basel, 4031 Basel/CH Ruptured aneurysm of the pancreatico-duodenal artery Objective: Key words: pancreatico-duodenal artery aneurysm, aorto-hepatic bypass Case Report Methods: Case report Results: A 48-year-old female presented to a peripheral hospital with acute epigastric abdominal pain, nausea and non-bilious emesis. An abdominal ultrasound showed cholecystolithiasis and signs of appendicitis. The patient underwent laparoscopy. 400 ml of blood in abdomine as well as a pulsating tumour close to the mesenteric root were found. A ruptured aortic aneurysm was suspected, the intubated patient was transferred to our hospital. Computed tomography of the abdomen showed a hematoma in the transverse mesocolon and an aneurysm of the pancreatico-duodenal artery, but no signs of acute bleeding. No signs of pancreatitis or atherosclerosis were present. An angiography showed the ruptured aneurysm and an almost complete occlusion of the celiac trunk. Spleen and liver were supplied by retrograde blood flow from the gastroduodenal artery. An attempt to dilate the celiac trunk failed. The patient underwent laparatomy. An aorto-hepatic bypass was performed, the gastro-duodenal artery was clipped and a cholecystectomy was carried out. After surgery the patient additio- 34 swiss knife 2006; special edition nally underwent endovascular coiling of the aneurysm. The postoperative course was unremarkable. No further aneurysms were found.The patient was discharged on the 13th postoperative day. Six weeks after surgery a duplex sonography showed good perfusion of the aorto-hepatic bypass. About 3 months after surgery occasional postprandial bloating and moderate pain from the scar were the only residues, CT-scan showed no perfusion of the aneurysm. Conclusion: Splanchnic aneurysms are infrequently encountered, peripancreatic artery aneurysms are highly unusual. Risk factors include a history of frequent pancreatitis episodes, and atherosclerosis. Absence of the celiac axis complicates treatment. Often the clinical presentation of a splanchnic aneurysm is dramatic. Yet, it is of importance to assess the patency of the celiac axis as well, to prevent infarction. Elective procedures include an open vascular approach and/or endovascular intervention. Associated aneurysms are common and ought to be excluded. 16.17 S.A. Bischofberger 1 , R. Kuster 2 , W. Nagel 2 1 Klinik für Chirurgie, Kantonsspital St.Gallen, 9000 St.Gallen/CH, 2 Klinik für Chirurgie, Kantonsspital St.Gallen, St.Gallen/CH Interne Qualitätskontrolle Karotischirurgie 2002 bis 2005 Objective: Seit 2002 werden am Kantonsspital St.Gallen Operationen an der Karotis immer in Intubationsnarkose und unter zerebraler Durchblutungskontrolle mittels intraoperativem SEP- Neuromonitoring (somatosensorisch evozierte Potentiale nach Medianusstimulation) durchgeführt. Wir erstellen seitdem jährlich einen Qualitätsbericht und vergleichen unsere Daten mit jenen der deutschen Gesellschaft für Gefässchirurgie DGG. Diese Daten erlauben Rückschlüsse auf die Qualität und ermöglichen Verbesserungsmassnahmen der operativen Versorgung. Nach dem Bericht 2004 wurde insbesondere die Durchführung des intraoperativen Neuromonitorings sowie einer intraoperativen Kontrollangiografie bei allen Patienten gefordert. Methods: Erfassung aller zwischen 2002 und 2005 an der Karotis operierten Patienten. Alle Patienten wurden präoperativ stadienunabhängig mittels Duplexsonografie und MR- Angiografie (selten CT-Angiografie) abgeklärt. Erfasst werden neben intraoperativen Daten zur Operationstechnik auch die postoperativen Komplikationen. Results: Zwischen 2002 und 2005 wurden 376 Patienten (2005: 107 Patienten) an einer Karotisstenose operiert. Operationstechnik: Konventionelle-TEA 368/104, Eversions-TEA 8/3, Patchplastik 362/98, Interponate 5/1, passagere Shunteinlage 140/25, Neuromonitoring 286/102, intraoperative Angiografie 91/34. Komplikationen: 3/0 schwere und 8/1 leichte neurologisch-ischämische Defizite, davon 6/1 passager, 5/0 permanent. Hirnnervenläsionen 33/6, revisionsbedürftige Nachblutung 20/4. Conclusion: Wie im Vorjahresbericht gefordert, konnte das intraoperative Neuromonitoring in 95% der Fälle (Vorjahr 72%) durchgeführt werden. Diese Steigerung war insbesondere durch die Aufstockung der personellen Ressourcen möglich. Somit konnten wir uns unserem Ziel von 100% deutlich annähern. Im Vergleich zum Vorjahr erreichten wir darunter eine weitere Senkung der neurologisch-ischämischen Komplikationen auf 1% (Vorjahr 5%). Das Auftreten der postoperativen revisionsbedürftigen Nachblutungen 3.5% und Hirnnervenläsionen 5% blieb im Vergleich zum Vorjahr konstant. Eine intraoperative Kontrollangiografie erfolgte in 32% (Vorjahr 51%). 16.18 C. Medugno 1 , P. Wigger 1 , R. Jenelten 2 1 Vascular Surgery, Kantonsspital Winterthur, 8401 Winterthur/CH, 2 Angiologie, Kantonsspital, 8401 Winterthur/CH Contained rupture of an infrarenal aortic aneurysm into the vertebral body Objective: Patients with a ruptured aortic aneurysm present usually with back-pain and signs of shock. Contained rupture of a true aortic aneurysm which presents as a false aneurysm sealed by the vertebral body is rareley seen and also classified as a chronic contained rupture. Methods: Case report: a 86-year-old man was admitted to the hospital with a several week history of lumbar back pain. There was marked progression of his pain in the last few days before admission so that the patient could hardly walk. Abdominal examination showed a pulsatile mass. The patient was haemodynamically stable. Laboratory findings showed an impaired renal function and an INR of 5.5. The patient was anticoagulated because of atrial fibrillation. A computed tomography revealed an 8cm abdominal aortic aneurysm and erosion of the adjacent L3 and L4 vertebrae. Results: The anticoagulation was reversed with concentrated coagulation factors (ProthromblexR) and the patient was operated on the day of admission. We decided to perform an open operation because of a marked kinking of the proximal neck. After opening the aneurysm there was a 2cm-circular defect of the back-wall of the aneurysm-sac with thrombus in the cavity of the eroded vertebral bodies representing a chronic sealed rupture into the vetebral body or a pseudoaneurysm. The aneurysm was repaired with a PTFE tube-graft. The operation was uneventful and straight forward. The postoperative course was complicated by pulmonary problems due to a known paresis of the right recurrent laryngeal nerve and swolling problems as a result of a former cerebrovascular event. Conclusion: Erosion of the vetebral body through pressure caused by the pulsating aneurysm sac is a rare but known manifestation of an aneurysm. A chronic contained rupture of an aneurysm into such an erosion representing a pseudoaneurysm of the aneurysms is even more rarely seen. 17 17.01 C. Tiffon 1 , E. Angst 2 , M. Rizzi 3 , S. Sibold 2 , D. Candinas 4 , D. Stroka 2 1 Department of Visceral and Transplantation Surgery, Department of Clinical Research, 3010 Bern/CH, 2 Department of Visceral and Transplantation Surgery, DCR, 3010 Bern/CH, 3 Haematology, Oncology, DCR, 3010 Bern/CH, 4 Department of Visceral and Transplantation Surgery, University of Bern, 3010 Bern/CH The role of the cellular differentiation on the hypoxia-induced expression of NDRG1 Objective: N-myc downstream regulated gene 1 (NDRG1) is a 43kDa protein that is up-regu
swissknife spezial 06 12.06.2006 13:39 Uhr Seite 35 lated in response to cellular stress including hypoxia. NDRG1 expression in tumors remains controversial, in some tumors, it has been described to be increased, while decreased in others. NDRG1 has also been described as a marker of cellular differentiation. The goal of our study was to verify that NDRG1 is induced during differentiation and to determine whether cellular differentiation is an important parameter that determines the up-regulation of NDRG1 in response to hypoxia. Methods: The myelomonocytic cell line U937 was treated with two differentiation inducers, phorbol myristate acetate (PMA, 16nM) or all-trans retinoic acid (ATRA, 1mM) for 4 days. Cell differentiation was confirmed by measuring the differentiation marker CD11b by FACS analysis. Cell morphology was examined by cytospin and staining with May-grünwald/Giemsa. Additionally a poorly differentiated pancreatic cancer cell line, Panc-1, was treated with an inhibitor of histone deacetylase, trichostatin A (TSA, 0.5mM) for 4 days alone or combined with 5-aza-2’-deoxycytidine, a DNA methylation inhibitor. The cells were exposed to hypoxia (1.5% 02) for 16 hours for the U937 cells or 24 hours for the Panc-1 cells. Real time-PCR and western-blotting were performed to evaluate NDRG1 mRNA and protein levels. Results: CD11b expression increased from 2.8 to 59 or 22.1 mean fluorescence intensity in U937 cells treated with PMA or ATRA respectively. The commitment of U937 cells was further confirmed by a change in morphology towards monocytes and granulocytes. NDRG1 mRNA was significantly up-regulated (15.6-fold) in differentiated U937 cells, whereas it was not increased in undifferentiated control (1.9-fold). Accordingly, NDRG1 protein was not increased in undifferentiated cells by hypoxia in comparison to a up-regulation in differentiated cells. The treatment of Panc-1 cells with TSA induced changes in cellular morphology accompanied by the restoration of NDRG1 expression under normoxia which was further increased by hypoxia Conclusion: Our results suggest that the differentiation status of a cell is an important modulator of NDRG1 expression in response to hypoxia. Hypoacetylation of histones associated with altered DNA methylation, may play a key role in the low expression of NDRG1 in undifferentiated cells. 17.02 A. Demirag 1 , C. Sogukpinar 2 , N. Güvener Demirag 3 , S. Karakayali 2 , M. Gonultas 4 , M. Kisakürek 5 , C. Ozturk 6 , N. Altan 6 1 Surgery&transplantation, Yed-Tepe University Hospitals, 34752 Istanbul/TR, 2 Surgery, Ankara Teaching&Research Hospital, Ankara/TR, 3 Endocrinology and Metabolism, Baskent University Hospital, Ankara/TR, 4 Pathology, Ankara Teaching&Research Hospital, Ankara/TR, 5 Surgery, Ankara Teaching&Research Hospital, Ankara/TR, 6 Biochemistry, Gazi University Hospital, Ankara/TR The effect of hepatic ischaemic preconditioning on intestinal ischemia-reperfusion injury and level of leptin in peripheral blood Objective: Ischaemia-reperfusion injury (IRI) of the intestine occurs commonly during solid organ procurement and continues to be a significant obstacle in small bowel transplantation. Hepatic ischemic preconditioning (HPC) provides a way of protecting the organ from damage inflicted by IR. It is not yet clear whether such HPC against IRI operates in the intestine. The aim of this study was to investigate the protective effect of HPC on intestinal IRI,development of distal organ dysfunction and to find out the role leptin(LP) in acute inflammatory responses. Methods: Rats were allocated to three groups: (1) sham, (2) IR consisting of 45 min of ischemia followed by reperfusion, (3) HPC, as in IR group, but preceded by two cycles of portal pedicle occlusion for 5 min and reperfusion for 10 min. Histological grading, tissue malondialdehyde (MDA), myeloperoxidase (MPO) and serum TNF , LP levels were assessed at 0 min, 2 hr, 24 hr and 48 hr of reperfusion. Results: Histological evaluation of small intestine showed leukocyte infiltration, focal necrosis and marked villus denudation or loss. Gr.III showed significantly reduced inflammatory infiltrates in the lamina propria and a greater villus height compared to Gr. II(p10 mol). 100 mol ZnCl2 abolished the histamine induced acid secretion about 90%. By adding IBMX (100 mol), a phosphodiesterase inhibitor, the inhibitory effect of ZnCl2 was not altered. We conclude that the ZnCl2 effect is cAMP independent. Furthermore we were able to show that ZnCl2 has a fast inhibitory onset effect on histamine induced acid secretion within seconds and this effect is reversible. Conclusion: This in vitro study demonstrates that ZnCl2 is a potent, fast acting and reversible inhibitor of gastric acid secretion, effective in a dose dependent manner. It is a naturally occuring drug, cheap and rarely toxic at very high concentrations. These data shows that zinc has great potential as an inhibitor of acid secretion. 17.05 A. Demirag 1 ,M. Kisakürek 3 , C. Sogukpinar 3 , M. Gonultas 4 , A. Sep-C 5 , S. Karakayali 3 1 Surgery&transplantation, Yed-Tepe University Hospitals, 34752 Istanbul/TR, 2 Surgery, Ankara Teaching&Research Hospital, Ankara/TR, 3 Surgery, Ankara Teaching&Research Hospital, Ankara/TR, 4 Pathology, Ankara Teaching&Research Hospital, Ankara/TR, 5 Biochemistry, Gazi University Hospital, Ankara/TR Protection against liver ischemia-reperfusion injury in rats by silymarin or glutamine Objective: Liver injury after cold or warm ischemia followed by reperfusion remains one of the major obstacles in transplantation.Various mechanisms have been implicated in liver ischemia-reperfusion injury(I-R), including reactive oxygen species generation, mitochondrial dysfunction, cytokine production. Some drugs that have properties of free radical scavengers and can prevent ischemia-reperfusion injury. Supplementation with glutamine (GLN) and silymarin(SLY) have been shown to have protective effects due to its ability to remove free radicals, prevent lipid peroxidation and depletion of glutathione. Although the possible cytoprotective effect of SLY and GLN have been studied but there is no information about the comparative effects of these drugs for over a period of time in ischemia-reperfusion by methods that can evaluate antioxidant and cytoprotective capacity. The aim of this study was to evaluate preventive effect of SLY and GLN supplementation against I-R injury. Methods: Sprague-Dawley rats were assigned to four groups: (i) sham (Group I); (ii) control with hepatic ischemia (clamping on the portal pedicle for 45 min and reperfusion); (Group II); (iii) SLY+ischemia (Group III); (iv) GLN+ischemia (Group IV); SLY and GLN were given 2 hours before ischemia. Blood samples and the liver were obtained after 45 min, 2hours and 24 h of reperfusion and malondialdehyde (MDA), superoxide dismutase (SOD), tumor necrosis factor (TNF ) levels and histopathologic findings were evaluated. Results: The liver MDA, SOD, and serum TNF- (p < 0.05) levels were significantly different in Group IV than in Group II at 45 min, 2h and 24h of reperfusion. The similar effects were seen in group III when compared with group II at 45 min and 24 h of reperfusion. While the effect of GLN on tissue MDA levels was significantly prominent than SLY group in all time frames (p < 0.05), the difference between these two groups was less significant for SOD. The TNF- levels were lower at 45 min and 2 h in group III compared with group IV. Both drugs decreased histopathological injury and reversed it. The most prominent ischemic injury was observed in Group III in which SLY was administered. Conclusion: These results suggest that GLN and SLY are effective in attenuating liver I-R injury and antioxidant effect of both medications could be responsible for the cytoprotection. 17.06 L. Mica 1 , L. Labler 2 , O. Trentz 2 , L. Härter 3 , M. Keel 2 1 Surgery, Trauma Surgery, 8006 Zürich/CH, 2 Chirurgie, Klinik für Unfallchirurgie, 8091 Zürich/ CH, 3 Trauma Surgery, Surgery, 8006 Zürich/CH Increased survival of neutrophil granulocytes in VAC-treated compared to Epigard-treated wounds Objective: Temporary covering of extensive soft tissue defects due to trauma or surgery has been performed with artificial skin covered with polyurethane foam on the surface, Epigard ® . Recently, a new product based on polyurethane and combined with a continuous negative pressure in the wound, VAC ® evolved. The mechanisms leading to accelerated wound-healing under VAC ® -therapy are still unclear. Therefore, we compared apoptosis of neutrophil granulocytes in wound from the two different types of wound cover. Methods: Wound fluid from VAC ® (n = 24) and Epigard ® -treated (n = 20) patients was acqui- swiss knife 2006; special edition 35
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