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Major clinical outcome at 1 year
Overall survival n =78
67 (86%)
Survival without major amputation n =78
63 (78%)
By-pass patency rates * n=78
primary patency 29 (43%)
secondary patency 38 (57%)
occlusion whitout major amputation 14 (21%)
Major amputations n=81
15 (19%)
* patency rates among living patients
Table 2. Major clinical outcome at 1 year
4.4
Reconstruction of the femoral bifurcation for peripheral arterial disease: a technical variation
C. Rouden 1 , T. Wolff 1 , T. Eugster 1 , T. Gürke 1 , P. Stierli 1,3 , C. Küng 2 , I. Langer 2 , C. Koella 2 ( 1 Basel, 2 Bruderholz,
3 Aarau)
Objective: Combined stenosis of proximal superficial femoral artery (SFA) and deep femoral artery
(DFA) is a frequent problem in patients with peripheral arterial disease (PAD). The standard procedure
in many institutions is endarterectomy of the femoral bifurcation and reconstruction with 2 synthetic
patches (Fig1). We present an alternative technique with its early results.
Methods: First an incision from the common femoral artery (CFA) continuing into the DFA and standard
endarterectomy of the CFA and DFA is performed. Then the SFA is transsected at a soft spot 2 to 5
cm distal to the bifurcation and an eversion-endarterectomy of the proximal SFA stump is performed
(Fig.2.a). The stump is then reanastomosed end to end to the native distal SFA. The arteriotomy of the
CFA and DFA is closed with a Dacron patch in a standard fashion (Fig.2.b). The 3 month outcome of 10
patients operated with this technique is reported.
Results: Median age was 76,8 y. (range 55- 86 y.). There were 6 men and 4 women. 6 patients were
Fontaine stage IIb, 4 stage IV. In 2 cases adjunct balloon dilatation of the distal SFA was performed. At
3 months after operation all patients were in stage lla and duplex scan showed a patent, stenose-free
reconstruction.
Conclusion: The technique described is an alternative to standard endarterectomy of the DFA and SFA
using two patch plasties. It has good short term results and appears to have many advantages: It
is technically simpler, as only one patch is used, reducing operation time; less synthetic material is
required, thus reducing costs and the potential of infection and finally the total length of the suture is
shorter, reducing the bleeding potential due to the stitches, which can be an advantage in patients
under anticoagulants or antiagreggants. The point where the SFA is transected can only be determined
intraoperatively, as it is very flexible, depending on the length of the stenosis and on where it is soft.
4.5
Long-term results of endoluminal interventions in patients with infrainguinal bypass stenosis
G. A. Prevost, G. Heller, M. Odermatt, M. Furrer (Chur)
Objective: Graft stenosis is a well known risk factor for occlusion in bypass surgery. This study examined
the results of percutaneous transluminal angioplasty (PTA) performed because of significant
infrainguinal bypass stenosis in patients having had surgery because of critical limb ischemia, claudication
or dilatative arteriopathy.
Methods: From January 1996 to December 2005, 215 consecutive patients with totally 271 infrainguinal
grafts have been included in our prospective single center study with a follow-up of fife years.
Patients have been controlled after 3, 6, 12, 24, 36, 48 and 60 month by clinical examination, oscillography,
ankle brachial index measurement and Duplex Scan. PTA was the choice of treatment in patients
presenting with stenosis of the graft or the anastomosis. Study endpoints, including primary patency,
primary assisted patency, and limb salvage were assessed by Kaplan-Meier life-table analysis.
Results: The average follow-up time was two years and fife month. The average time until the first
10 swiss knife 2010; 7: special edition
significant stenosis was 12 month (range 0-58 month). PTA was used to treat 57 limbs (21%), 36 patients
(17%) had one, 21 patients (10%) multiple interventions. 71 stenosis (26%) have been detected
in the context of the surveillance program in patients free of symptoms, 23 (8%) because of clinical
symptoms. In all patients the 36-and 60-month primary non-assisted patency rate was 43% and 36%,
primary assisted patency was 64% and 59% and limb salvage was reached in 84% and 82%, respectively.
Patients in the PTA group had a significant lower occlusion rate than patients that never had a
PTA after bypass operation.
Conclusion: Trying to assist primary patency in infrainguinal bypass surgery every forth patient has
to undergo an invasive reintervention. PTA seems to be an effective treatment of secondary stenosis
mainly detected during the first three years of follow-up programs.
4.6
Hybrid procedure combining endovascular and open surgery in multilevel arterial disease is the past,
the present and the future of lower limb revascularization
F. Saucy, S. Déglise, A. Mennet, C. Bron, C. Haller, J.-M. Corpataux (Lausanne)
Objective: To evaluate the feasibility and efficacy of simultaneous combined endovascular and lower
extremity arterial reconstruction.
Methods: We designed a case series study with retrospective analysis of prospectively collected non
randomised data of patients who underwent simultaneous endovascular and open surgery in operating
room. Patency rates were analysed by Kaplan-Meier life tables. The multivariate analyses were
used to assess the influence of various risk factors on primary patency.
Results: 35 hybrid procedures were performed in 31 patients. Technical and clinical successes were
100% and 94% respectively. The perioperative mortality rate was 3%. The primary, primary assisted
and secondary rates at 12 months were 70%, 74% and 94% with a limb salvage of 96% at 1 year. No
independent factors were found to influence the primary patency. Endovascular treatment was used to
treat inflow and outflow lesions in 30% and 70% respectively.
Conclusion: Hybrid procedure is an efficient therapeutic option for patients with multilevel arterial disease.
Patency rates, clinical success and limb salvage are comparable to all open surgery alternative
and could be recommended in patients without sufficient venous length or to perform shorter bypasses.
Endovascular procedures are improved by surgical access in long arterial occlusions.
Visceral Surgery – Endocrine Surgery 05
5.1
Postoperative hypoparathyroidism after thyroid surgery – who’s at risk?
J. M. Janczak, W. Kolb, U. Beutner, T. Clerici (St. Gallen)
Objective: In contrast to postoperative recurrent nerve palsy, postoperative transient or permanent
hypoparathyroidism is less well studied. Furthermore the lack of a generally accepted definition of hypoparathyroidism
makes it difficult to compare study results. Hypoparathyroidism affects patients in
their wellbeing and requires lifelong replacement therapy, consultations and laboratory tests causing
considerable costs. The aim of this study was to evaluate the incidence of hypoparathyroidism depending
on type of surgery and initial diagnosis.
Methods: From January 2001 to September 2008 data of all patients undergoing uni- or bilateral thyreoidectomy
were prospectively collected. Retrospectively 398 patients with no risk for postoperative
hypoparathyroidism (e.g. hemithyroidectomy, thyroid biopsy etc.) were excluded, leaving 668 patients
included in this study. Follow-up of postoperative hypoparathyroidism was performed by the operating
surgeons for at least 18 months or until full recovery of parathyroid function. Permanent postoperative
hypoparathyroidism was defined by inadequate PTH-levels (< lower lab normal limit) and unsuccessful
weaning from vitamin D-replacement therapy 18 months after the operation.
Results: The overall rate of permanent postoperative hypoparathyroidism was 2.1% (14 patients,
95% confidence interval (1.2-3.5%). After total thyroidectomy the risk was 2.8% (10/354) and after a
Hartley-Dunhill resection 1.2% (1/86). For patients requiring completion thyroidectomy for malignant
disease or goiter recurrence, following an initial hemithyroidectomy, the rate of hypoparathyroidism
was 1.6%. Based on the preoperative diagnosis, patients undergoing thyroidectomy for malignant
disease had the highest rate of hypoparathyroidism (3.1%, 4/128, p=0.32), followed by patients with
concomitant hyperparathyroidism (2.4%, 2/84), recurrent benign goitre (2.3%, 1/43) and Graves‘
disease (2.1%, 2/97).
Conclusion: Our overall rate of permanent postoperative hypoparathyroidism of 2.1% is within the
range of published values (1.7-4.4%). However, comparisons with published data have to be interpreted
cautiously due to differing definitions of permanent postoperative hypoparathyroidism.
5.2
Une approche multidisciplinaire (pathologie, endocrinologie, chirurgie) des nodules thyroïdiens
avec un cytopathologue sur place permet de réduire le taux de prélèvements non-diagnostiques et
d’accélérer la prise en charge des patients
F. Triponez, P. Meyer, M. J. Molliet, K. Helfer Guarnori, J. Robert, S. Gaillard, P. Soardo, M. Bongiovanni
(Genève)
Objective: La cytoponction échoguidée fait partie du standard actuel de la prise en charge des nodules
thyroïdiens > 1cm, afin d’en déterminer leur nature. La cytoponction est grevée d’un taux de prélèvements
non diagnostiques dans > 10%, nécessitant de répéter celle-ci lors de nouvelles consultations,