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

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swissknife spezial 06 12.06.2006 13:39 Uhr Seite 46 Surgical treatment of pulmonary artery aneurysms: indications and techniques Objective: Despite refined diagnostic tools and operative strategies treatment of pulmonary artery aneurysms (PAA) remains controversial. Aim of this study was to determine if surgery of this rare condition is safe and relieves symptoms even in the presence of cardiac comorbidities Methods: From 10/04 to 10/05 three patients with aneurysms of the main pulmonary artery and/or the pulmonary artery branches with a diameter of 53mm, 57 mm and 62 mm respectively presented with atypical chest pain or dyspnoe NYHA II, associated with aneurysms of the ascending aorta in two, with a secundum atrial septal defect (ASD) and a persistent left superior vena cava (LSVC) draining into the coronary sinus in one, and with severe aortic stenosis in one. Results: All patients underwent supravalvular replacement of the main pulmonary artery, one with additional replacement of both branch pulmonary arteries. Concomitantly, two underwent supracoronary replacement of the ascending aorta, one direct closure of a secundum ASD and one aortic valve replacement. The hospital course was uneventful in all patients. During a mean follow-up of 10 months all patients became fully asymptomatic. One patient underwent pacemaker implantation six month later due to sick-sinus-syndrom. CT and MRI controls six months postoperatively showed excellent postoperative results. Conclusion: Surgery of PAA can be performed safely with excellent results even in the presence of important cardiac comorbidities. Considering these results and the fact, that large PAAs carry a substantial risk of fatal rupture, patients should be evaluated for surgery. 27.03 M. Faeli 1 , S. Demertzis 2 , G. Franciosi 1 , F. von Rotz 1 , F. Siclari 3 1 Cardiac Surgery, Cardiocentro Ticino, Lugano/CH, 2 Cardiac Surgery, Cardiocentro Ticino, 6900 Lugano/CH, 3 Cardiochirurgia, Cardiocentro Ticino, 6900 Lugano/CH Extending the indications for aortic root replacement: striving for the best or asking for trouble? Objective: In several surgical scenarios, replacing the aortic root seems prognostically reasonable even when the formal criteria with regard to the dimensions of the ascending aorta are not met. Such an aggressive strategy would only be justified, if it would not significatively increase surgical risk. Aim of this retrospective, case-matched study is to compare early surgical outcomes after aortic valve or aortic root replacement (modified Bentall procedure). Methods: Two patient groups, IAVR (isolated aortic valve replacement, n=51) and MBENT (modified Bentall, n=43) operated upon between 2001 and 2005 were matched for age, left ventricular ejection fraction (LVEF), NYHA class and Euroscore. Compared were early mortality, reexploration for bleeding, stroke, pacemaker implantation, length of stay (LOS) in intensive care unit and in hospital. Results: Differences bewteen match criteria were not statistically different: for IAVR and MBENT respectively, mean ages was 69.4 vs. 66.9, the male/female ratio was 0.8 vs 0.5, mean LVEF was 59.4 vs 59.9, percentage of pts in NYHA class >II was 19 vs 25 and mean Euroscore was 10.6 vs 11. For IAVR and MBENT respectively, early mortality was 3.9 vs 0 (ns), mean ECC time 122.2 vs 122.4 min (ns), mean aortic cross clamp time 54.8 vs 77.4 (p3.1cm. A stent length of >2.4cm will allow anchoring above the STJ. The depth of the sinus portions is sufficient for a non-obstructed coronary flow after Valved Stent implantation for non-covered stents 28 28.01 C.T. Viehl 1 , G. Sauter 2 , U. Güller 3 , I. Langer 4 , M. Richter 5 , A. Ochsner 6 , W.R. Marti 7 , U. Laffer 8 , D. Oertli 9 , M. Zuber 10 1 Departement Chirurgie, Universitätsspital Basel, 4031 Basel/CH, 2 Institut für Pathologie, Universität Basel, 4031 Basel/CH, 3 Department of Surgery, University Hospital Basel, 4031 Basel/CH, 4 Visceral, Vascular and Transplantation Surgery, University Hospital Basel, 4031 Basel/CH, 5 Departement Chirurgie, Spitalzentrum Biel, 2501 Biel/CH, 6 Departement of Surgery, Kantonsspital Olten, 4600 Olten/CH, 7 Department Chirurgie, Unversitätsspital Basel, 4031 Basel/CH, 8 Chirurgische Klinik, Spitalzentrum, 2502 Biel/CH, 9 Department of Surgery, University Hospital Basel, 4031 Basel/CH, 10 Departement of Surgery, Kantonsspital Olten, 4600 Olten/CH Mikrometastasen im Knochenmark und Metastasen in Sentinel-Lymphknoten sind unabhängige Indikatoren einer Tumorzelldissemination bei Kolonkarzinom-Patienten Objective: Der Nachweis von Mikrometastasen im Knochenmark (KM) scheint beim kolorektalen Karzinom ein unabhängiger Prognosefaktor zu sein. In früheren Studien wurden die resezierten Lymphknoten allerdings nur konventionell-histologisch beurteilt. Dank fokussierter Aufarbeitung von Sentinel-Lymphknoten (SLN) mittels Stufenschnitten und immunhistochemischer Färbung werden kleine, nodale Tumorinfiltrate in einer beträchtlichen Anzahl entdeckt. Mit dieser Multizenterstudie sollte eruiert werden, ob Mikrometastasen im Knochenmark und Metastasen in Sentinel-Lymphknoten unabhängige Indikatoren einer Tumorzelldissemination bei Kolonkarzinom-Patienten sind. Methods: Bei 98 Kolonkarzinom-Patienten wurde eine KM-Aspiration gefolgt von einer offenen, onkologischen Kolonteilresektion und SLN-Verfahren (Isosulfanblau 1%) nach einem standardisierten Protokoll durchgeführt. Drei Stufenschnitte jedes SLN wurden je mit HE und mit dem Panzytokeratin-Marker AE1/AE3 gefärbt. Die mononukleäre Zellfraktion des KM
swissknife spezial 06 12.06.2006 13:39 Uhr Seite 47 Aspirates wurde mit dem Panzytokeratin-Marker A45-B/B45 gefärbt und in einem automatischen Bild-Analysesystem auf epitheliale Tumorzellen untersucht. Ein Pathologe verifizierte positive Befunde visuell. Results: Die SLN-Identifikation gelang in 82/98 Fällen (84%). Median wurden 3 SLN (Variations-breite 1-13) gefunden. Bei 16 Patienten (20%) wurden SLN-Makrometastasen diagnostiziert. Bei 8 Patienten (10%) konnten Mikrometastasen oder isolierte Tumorzellen in den SLN nachgewiesen werden. In 58 Fällen (70%) wurden keine nodalen Tumorinfiltrate beobachtet. Die KM-Analyse war positiv bei 15 SLN negativen (18%) und 6 SLN positiven Patienten (7%); die KM-Analyse war negativ bei 43 SLN negativen (53%) und 18 SLN positiven Patienten (22%). Es bestand keine Korrelation (p = 1,0; Fisher’s exact-Test) zwischen dem Nachweis von KM- und SLN-Metastasen. Positive KM-Aspirate zeigten im Durchschnitt 7 epitheliale Tumorzellen pro 50 Millionen Zellen. KM-Mikrometastasen konnten in 5/16 Patienten (31%) mit SLN-Makrometastasen und 1/8 Patienten (12%) mit SLN-Mikrometastasen oder isolierten Tumorzellen nachgewiesen werden (p = 0,6; Fisher’s exact-Test). Conclusion: Der Nachweis von Mikrometastasen im Knochenmark und von Metastasen in Sentinel-Lymphknoten korreliert bei Kolonkarzinom-Patienten nicht. Daher sind beide Befunde als unabhängige Indikatoren einer Tumorzelldissemination des Kolonkarzinoms zu bewerten. 28.02 R. Ipaktchi 1 , B. Egger 2 , G. Beldi 3 , D. Candinas 4 1 DMLL, Klinik und Poliklinik für Viszerale und Transplantationschirurgie, 3010 Bern/CH, 2 Department of Visceral and Transplantation Surgery, Inselspital, University of Bern, 3010 Bern/CH, 3 Clinic of Visceral and Transplantation Surgery, Inselspital Bern, 3010 Bern/CH, 4 Vchk, Inselspital, Bern/CH GIST-Patienten: Gutes Langzeitüberleben trotz hoher Rezidivrate mittels repetitiver resezierender Chirurgie und Imatinib-Therapie Objective: Gastrointestinale Stroma Tumore (GIST) machen 1-3 % aller gastrointestinalen Malignome aus. Die Prognose richtet sich nach der Fletcher Klassifikation, bei welcher die Mitoseaktivität und die Grösse der Tumore bedeutend sind. Wichtig ist auch die chirurgische Resektion im Gesunden ohne „Spilling“. Ziel der Studie: Analyse der Behandlungsergebnisse unseres Krankengutes mit GIST. Methods: Zwischen 1995 und 2005 wurden bei uns 41 Patienten (23 Männer, 18 Frauen, Durch-schnittsalter: 67 Jahre) mit GIST bei behandelt. Dabei konnten retrospektiv bei 31 Patienten die Symptome, Operation, Tumorlokalisation, Klassifikation nach Fletcher und Rezidive erfasst werden. Results: Symptome: GI-Blutung 27%, Schmerzen 20%, Gewichtsverlust 13%, Dysphagie 7%, pal-pabler Tumor 6%, keine Symptome 27%. Lokalisation: Magen 52%, Dünndarm 25%, Ösophagus 13%, Kolon/Rectum 3%, retroperitoneal 7%. Ferner zeigte sich bei 23% ein synchroner maligner Zweit-Tumor. Chirurgisches Vorgehen: laparoskopisch 10%, offen 90%. Resektion: R0-Resektion in 71%, R1-Resektion in 13%, Enukleation in 16%. Perioperative Mortalität: 0%. Fletcher Klassifikation: Grad I: 35%, Grad II: 29%, Grad III: 13%, und Grad IV: 22%. Nach einer medianen Beobachtungszeit von 47 (4-119) Monaten zeigten 26% der Patienten nach durchschnittlich 32 (13-66) Monaten Rezidive: 57% bei Grad IV- (38 Mo) 25% bei Grad III- (35 Mo.), 11% bei Grad II (13 Mo) und 18% bei Grad I-Tumoren (29 Mo). 3 Patienten sind verstorben, wobei nur einer am Tumorleiden. 6 Patienten wurden im Verlauf mit Imatinib (4 bei Rezidiv, 2 ohne Rezidiv) behandelt und bei 6 Patienten wurden z.T. multiple Resektion durchgeführt (-8x). Conclusion: GIST sind maligne Tumor mit hohen Rezidvraten. Auch bei „low-risk“ -Tumoren (Grad I n. Fletcher) findet sich immer noch ein Rezidivrate von fast 20% („high risk“: 57%). Allerdings kann mit onkologischer Chirurgie (z.T. multipel) und dem Einsatz von Imatinib (Glivec), unabhängig vom initialen Tumorstadium und dem Auftreten von Rezidiven, ein gutes Langzeitüberleben erreicht werden. Mit Ausnahme eines Patienten (Grad IV mit Peritonealkarzinose; 17 Monate Überleben) und einer anderen (Sepsis nach Narbenhernienrepair) sind alle Patienten mit Rezidiven nach durchschnittlicher Verlaufszeit von 87 Monaten (49 –119 Mo) am Leben. 28.03 D. Perez 1 , N. Demartines 1 , D. Jaeger 2 , P. Clavien 3 1 Dept. of Visceral and Transplant Surgery, University Hospital of Zurich, 8091 Zurich/CH, 2 Nat. Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg/DE, 3 Swiss Hpb Center, Dept. Visceral and Transplant Surgery, University Hospital of Zurich, 8091 Zurich/CH Prognostic value of protein S100 expression in gastrointestinal stromal tumor Objective: To assess the prognostic value of protein S100 expression in Gastrointestinal Stromal Tumor (GIST) in patients undergoing a curative resection. GIST tumors display a high variability in their malignant behaviour. The only established predictors of poor outcome are the mitotic rate and the size of the tumor. Protein S100 expression is found predominantly in neurogenic tissue and is an established tumor marker for melanoma. S100 expression in GIST varies between 5% and 76%, but its prognostic value has not been described yet. We hypothesize that S100 expression may predict outcome in patients undergoing a curative resection. Methods: Clinical and histopathological slides of 35 GIST patients after curative resection in our institution between 1995 and 2004 were reviewed. The following data were analyzed for their putative value in predicting outcome: age, gender, primary tumor site, size, mitotic rate, positive immunostaining (S100, desmin, alpha smooth muscle actin (aSMA), CD117 and CD34). Tumors were designated positive for immunostaining when more than 10% of the tumor cells showed a positive reaction. Primary endpoints in this study were survival and recurrence after complete resection. Results: Among the 35 patients, there were 18 men and 17 women with a median age of 48 years. The median follow-up was 52.2 months (1-235 months). At the time of analysis 29 patients (82.9%) were alive and 6 (17.1%) had died from GIST. Immunostaining was positive for S100 in 33% of the patients, for CD117 in 71%, for CD34 in 54%, for aSMA in 22% and for Desmin in 9%. The multivariate analysis identified positive immunoreactivity for S100 to be the sole significant marker of poor prognosis (p=0.0058). All other tested markers did not correlate with prognosis. Consistent with previous report, tumor size was also identified as a significant prognostic factor (p=0.034). A trend for poor prognosis was also documented in patients with a high mitotic activity (p=0.06). Age, gender and primary tumor site failed to indicate a poor outcome. Conclusion: The present series suggests that the expression of S100 is an excellent novel predictor of poor prognosis after curative resection of GIST. Taken together with the size of the tumor and the mitotic rates, S100 may become an important additional marker to grade the malignant potential of GIST. 28.04 O.J. Wagner 1 , C. Von der Brelie 1 , S.W. Schmid 2 , D. Candinas 3 , C.A. Seiler 4 1 Dpt. of Viszeral and Transplantation Surgery, Inselspital, University of Bern, 3010 Bern/CH, 2 Visceral and Tranplantation Surgery, University Hospital of Bern/Inselspital, 3010 Bern/CH, 3 Vchk, Inselspital, Bern/CH, 4 Visceral and Transplantation Surgery, University Hospital of Bern, 3010 Bern/CH Lymphadenectomy (modified neck dissection) and its morbidity in well differentiated thyroid cancer: is it justified? Objective: Due to the natural history and the slow clinical evolution of well-differentiated thyroid cancer (DTC) the influence of lymphadenectomy (LA) on late mortality is not yet clarified. According to the generally accepted treatment strategies for oncologic diseases, radical resection with (neo-) adjuvant treatment is a therapeutic standard. According to this we perform in DTC total thyroidectomy (TR) combined with initial LA of the cervico-central and ipsilateral cervico-lateral compartment (modified neck dissection, MND). The short term aim of this study is to evaluate the negative effects (additional morbidity) of this extended approach and wether this procedure is recommendable in all cases with DTC. Methods: Between 1995 and 2005, 181 patients (140 female/ 41 male), mean age of 52±18 years with DTC (137 papillary thyroid carcinoma/ PTC, 44 follicular thyroid carcinoma/ FTC) underwent surgery. Extent of the surgery was based on histological diagnosis provided either by intraoperative frozen section or rapid definitive histology within max. 36 hours. All patients with intraoperatively diagnosed malignoma underwent TR and MND (Group A, n=73). Patients with unclear intraoperative diagnosis (n=108), but malignancy in early definite workup (max 36h) underwent completion thyreoidectomy (if not primarily performed, n=38) with (Group B, n=51) or without MND (Group C, n=57) within 3,9±1,8 days. Excluded of this procedure were patients with significant co-morbidity. Morbidity of all patients was collected prospectively but evaluated retrospectively. Tumor stage: pT1, n=61; pT2, 62; pT3, 29; pT4; 29. Results: Sensitivity of intraoperative histological diagnosis was 43,2%. Specific morbidity included permanent recurrent laryngeal nerve palsy (A=3.9%, B=3,4%, C=1,1%) and permanent hypocalcaemia (A= 1,4%, B=0,9%, C=1,1%) as main criterias. General complications as lymphatic fistula and secondary hemorrhage were seen in 6,8 % of group A, 1,7% group B and 2,1% group C. (Specific Morbidity was in all groups n.s.) Conclusion: The „additional” morbidity of MND in combination with initial thyreoidectomy or early completion surgery seems to be insignificant in patients. We conclude that therefore this in other fields oncologic correct strategy should be included in primary surgery for all patients with DTC. The influence of this „correct” oncologic surgical concept on late morbidity will be further evaluated. 28.05 B. Roche 1 , G. Zufferey 2 , J. Robert-Yap 3 1 Chirurgie, Unité de Procotlogy HUG, 1211 Geneve 14/CH, 2 Chirurgie, Hôpital Zone de Nyon, Nyon/CH, 3 Chirurgie, hug procotologie, 1211 Geneve 14/CH Results of 53 surgical decompression of pudendal nerve neuralgia Objective: Anatomy: The pudendal nerve supplies the principle innervation of the perineum. The pathway of this nerve runs deeply through the perineum and is subjected to compression in various zones: between the infra-spinous and the sacro-coccygeal ligaments, between the sacro-tuberal and the sacro-spinous ligaments, and in Alcock’s canal, at the level of the obturator internus. This compression can lead to a syndrome of perineal pain. Methods: Symptoms: The signs and symptoms of this syndrome are typical of a classical nerve compression syndrome. However, due to its atypical location and presentation, perineal pain due to pudendal nerve compression, presents a diagnostic challenge. The pain of pudendal nerve compression is often described as burning in the perineum, occurring consistently in the same region, unilaterally, and increasing in sitting position. These symptoms should evoke the thought of pudendal nerve compression. Results: Diagnosis and Treatment: The diagnosis relies heavily on a good history and clinical examination. Electrophysiological tests and diagnostic imaging are useful to exclude other pathology. From January 2000 to February 2004 diagnostic infiltration was performed in 112 patients in our institution. The pain diminished in 97 cases. Infiltration alone was therapeutic in 27 patients (24.1%). In 35 out of 53 patients (66.1%), symptom relief was achieved one year after posterior transgluteal decompression surgery. 18 patients had no amelioration of the pain. Degradation of the symptoms was not noted after treatment. Conclusion: Conclusion: Pudendal nerve compression is not a rare condition. Diagnosis is based on the history and physical and confirmed with infiltration. The infiltration alone can treat the pain in 24% of the cases. Decompression surgery may be proposed when the pain is recurs. The post operative success rate is 66.1% in our series. The effect is not immediate, possibly taking up to one year for maximal benefit, and the patients should be informed of this prior to the procedure. A multidisciplinary approach to the treatment of this chronic pain syndrome is mandatory. 28.06 J.M. Heinicke 1 , D. Candinas 2 , B. Egger 2 1 Vchk, Inselspital, 3010 Bern/CH, 2 Vchk, Inselspital, Bern/CH Distal malabsorptive Roux-en-Y gastric bypass with minimal restrictive component for the treatment of super- and mega-obesity: pilot study results Objective: Gastric bypass procedures are mainly based on restriction and may be combined to different degrees of malabsorption. They are associated with specific long-term consequences on quality of life and longterm maintenance of weight loss. We present early results using a distal, essentially malabsorptive Roux-en-Y gastric bypass (mRYGB) with only minimal restrictive component for patients with a BMI >50 and >60 kg/m2. Methods: Unlike the classical Roux-en-Y gastric bypass, we avoided the implied restrictive measures by forming a gastric pouch of at least 60 ml. The whole small intestine was measured, a biliopancreatic limb of 100 cm and a common channel of 110 – 150 cm depending on the actual BMI of the patient were created. The rest of the small bowel was used as alimentary limb. 15 consecutive open and 8 consecutive laparoscopic procedures were prospectively analysed. swiss knife 2006; special edition 47
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