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group (conventional: n=13, RS=1.8 +- 0.9 mm; locking: n=20, RS=0.3 +- 0.6 mm; p90%) endogenous hyperinsulinemic hypoglycaemia is due to a small, benign
neuroendocrine tumour located in the pancreas. After establishing the diagnosis by a fasting test
the workup aims at localizing the insulinoma to facilitate the intraoperative localisation of the tumour.
The probability of cure depends on the surgeon’s ability to identify the tumour intraoperatively based
on the preoperative imaging and intraoperative localisation techniques (palpation, ultrasound). GLP-
1 receptors (GLP-1 R) show a very high density in insulinomas. GLP-1 scintygraphy uses an indium
labelled specific ligant to GLP-1 R (111In-DOTA-exendin-4 ) to perform SPECT/CT –imaging in order to
localize insulinomas.
Methods: We present the experience of a prospective pilot study from two tertiary referral centres in
endocrine surgery. In addition to the classical radiological workup five patients (3 women, 2 men;
median age 44 years) with hyperinsulinemic hypoglycaemia agreed to have GLP-1 R scintigraphy
maximally 14 days before surgery. Intraoperatively a gamma-probe was use as an adjunct localizing
tool in all patients.
Results: Crossectional imaging (MRI/CT) failed to localize the insulinoma in 3 cases. Arterial stimulation
and venous sampling correctly predicted the localisation in 3 out 4 investigated patients. GLP-1R
scintigraphy correctly identified the insulinomas in all (5/5) patients. 4 insulinomas were located in the
head and the corpus of the pancreas - one insulinoma was ectopic in the mesentery of the jejunum. In
all patients the detection and identification of the tumours by gamma-probe was deemed to be easy
and accurate. All insulinomas were verified by histology and receptor autoradioloy. The median diameter
was 13mm (range 10-18 mm).All patients are clinically cured at follow up.
Conclusion: GLP-1 R scintigraphy is a new, very accurate and promising imaging technique for neuroendocrine
insulin producing tumours. It could potentially reduce the multitude of usually performed
preoperative localisation techniques and give the surgeon a very potent intraoperative adjunct in case
he cannot localize the tumour by palpation or ultrasound.
9.2
Randomisiert kontrollierte Studie zur Evaluation des bilateralen oberflächlichen Zervikalblocks in der
Schilddrüsenchirurgie unter Allgemeinanästhesie
T. Steffen, R. Warschkow, M. Brändle, I. Tarantino, T. Clerici (St. Gallen)
Objective: Der bilaterale oberflächliche Zervikalblock bei Schilddrüseneingriffen unter Allgemeinanästhesie
kann die postoperativen Schmerzen reduzieren. Die Wirkung und die beste Form der
Applikation des Zervikalblocks sind jedoch unklar. Diese randomisiert kontrollierte Studie erfasst die
Wirkung dieser Regionalanästhesie bezüglich postoperativer Schmerzen nach Schilddrüseneingriffen.
Methods: Patienten wurden in einem doppelblinden Studiendesign in vier Gruppen randomisiert. Die
Randomisierung erfolgte in Gruppen mit einem Zervikalblock mit Bupivacaine oder Placebo, appliziert
vor oder nach der Operation. Postoperativer Schmerz, Schmerzmittelverbrauch und Hospitalisationsdauer
wurden verglichen.
Results: In der intention to treat Analyse wurden 159 Patienten ausgewertet. Die Gruppe mit Bupivacaine
hatte signifikant weniger Schmerzen als die Placebogruppe (P=0.0160). Prä- versus postoperative
Verwendung von Bupivacaine hatte keinen signifikanten Einfluss auf die Schmerzen
(P=0.7230). Kein Unterschied zeigte sich bezüglich dem Schmerzmittelverbrauch, und die Hospitalisationsdauer
war unabhängig von der Verwendung von Bupivacaine oder Placebo (P=0.9254) oder
ob Bupivacaine am Anfang oder am Ende der Operation eingesetzt wurde (P=0.0874).
Conclusion: Der bilaterale oberflächliche Zervikalblock mit Bupivacaine in Kombination mit der Allgemeinanästhesie
reduziert postoperative Schmerzen nach einem Schilddrüseneingriff signifikant. Bei
Ausbleiben von mit dem Zervikalblock assoziierten Komplikationen kann diese kostengünstige und
effiziente Massnahme für alle Patienten mit Schilddrüseneingriff empfohlen werden.
9.3
How many thyroid resections are performed annually in Switzerland and how many are performed
by residents in training?
C. Maurus, W. Kolb, N. Kalak, T. Clerici (St. Gallen)
Objective: To date, reliable figures for thyroid operations performed in Switzerland are not available, although
thyroid resections are required for the surgical board certificate catalogue. The aim of this study
was to evaluate the teaching potential in thyroid surgery by analysing how many thyroid interventions
are performed annually and by whom.
Methods: Questionnaires were sent to all heads of surgical and ORL units, as well as to specialists
in private practice (N=42) in the cantons of St. Gallen, both Appenzell and Glarus (total population:
578’000). Questions included the total number and the extent of thyroid resections performed in 2008,
the insurance status of patients and the number of procedures performed by surgeons in training under
supervision.
Results: The questionnaire return rate was 76% (32 of 42), 14 questionnaires came from public and 18
from private facilities. A total number of 240 thyroid interventions were identified in 9 public and 2 private
institutions. Extrapolated, this would correspond to 3’200 thyroid procedures in entire Switzerland
per year. The predominant resection types were hemithyroidectomy (53%) and total thyroidectomy
(39%). Of the 75 procedures performed as teaching operation (31%), only 23 (9.6% of total) were
performed by residents in training, while 52 (21.7%) were performed by board-certified surgeons. Only
in 5 out of 12 public surgical units, residents in training without board certification performed thyroid
resections under supervision.
Conclusion: The global trend from bilateral subtotal thyroid resections to more demanding and radical
resections (hemi- or total thyroidectomy) seems to shift the training of thyroid surgery to a much
later time point during the career and requires in most cases already a board certification. Thus, for
residents in training opportunities for teaching operations are constantly declining. Consequentially,
the required number of operative interventions in thyroid surgery for surgical board certification should
be adjusted.
Visceral Surgery – Hepatobiliary and Pancreatic Surgery 12
12.1
A score predicting the occurrence of complications after liver resection
A. Andres, C. Toso, Ph. Morel, S. Hauss-Meyer, L. Rubbia-Brandt, S. Terraz, E. Schiffer, C. E. Klopfenstein,
P. E. Majno, G. Mentha (Geneva)
Objective: Surgery remains the main hope of cure for many liver focal tumours. Thanks to refinements
in the peri-operative management, liver resections can be offered to patients with higher morbidity and
with pathologies of higher grades. The aim of this study was to analyse the factors associated with
post-operative complications and to design a score predicting their occurrence.
Methods: All liver resections performed in our institution between 01.01.1991 and 31.10.2009 were
prospectively included and retrospectively analyzed. Age, gender, ASA score (1-2 vs ≥3), pre-operative
haemoglobin and prothrombin time, indication of surgery (benign vs. malignant), extent of surgery
(< 3 segments vs. ≥ 3 segments), red blood cells transfusion, associated surgical procedures, cirrhosis,
clamping time and drainage were analysed. Complications were defined according to a modified
classification described by Clavien et al., Surgery 1992 (we added a grade IIc = reoperation). Complications
≥ grade IIb required invasive procedure and were considered as major. Multivariate analyses
were performed with linear regression, dichotomous data were analysed with Chi-Square test, multiple
(>4) continuous variables were analysed with an ANOVA test.
Results: 726 liver resections were performed. No difference in the rate of complication was observed
over time. Overall mortality was 0.7%. A score was assessed for the period 1991-2004 (n=487) and
validated on the period 2005-2009 (n=239). ASA score ≥ 3, extent of resection ≥ 3 segments and
malignant pathology were independent pre-operative variables associated with complications after
surgery (p = 0.012, 3 segments) and colorectal surgery has gained increasing
attention in patients with synchronous hepatic metastases from colorectal cancer. However,
safety of simultaneous surgery remains unclear since published case series are small, not adjusted for
confounders, and therefore may include a relevant selection bias. To assess the postoperative outcome
and safety of simultaneous liver resection and intestinal surgery the current study was performed.
Methods: Between 2002 and 2008, consecutive patients presenting with synchronous intestinal
and liver tumors were assessed based on our prospective database. Simultaneous resection was
compared with staged procedures. Postoperative outcome data were statistically adjusted for age,
preoperative chemotherapy, extent of liver resection, type of bowel resection, liver steatosis and comorbidities.
Results: A cohort of 101 patients with synchronous intestinal/liver tumors was included. Surgery was
performed simultaneously in 29, and staged in 72 patients. The overall incidence of complications
(Grade I-V) was not significantly different between groups (p=0.9). However, severe complications
swiss knife 2010; 7: special edition 13