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the anorectal part of the intestine. All these lesions are accessible by performing a digital rectal exam and a bedside anorectoscopy +/- biopsy with a rigid anorectoscop. These two examinations are simple and fast, inexpensive and safe and offer to obtain the right diagnosis in half of the patients with lower G-I-bleeding. Additional time-consuming and expensive investigations, as CT-scan, gastroscopy, angiography and others may be avoided. 43.2 Sacral nerve stimulation for faecal incontinence: loss of function considerably leads to increase of costs D. Kisner, D. Hahnloser, D. Dindo (Zurich) Objective: Sacral nerve stimulation (SNS) was repeatedly shown to be successful in the treatment of faecal incontinence and to be cost-effective. However, in some patients, the electrode and the implantable pulse generator (IPG) have to be removed. The aim of this study was to analyse the reasons for device removal. Moreover, the financial burden of failed SNS was calculated. Methods: Consecutive patients with faecal incontinence, who underwent percutaneous nerve evaluation at the Department of Surgery of the University Hospital Zurich between 2001 and 2009, were evaluated. Data were prospectively recorded. For cost analyses, only direct costs have been considered. Results: One hundred and three patients (80 females, 23 males) underwent percutaneous nerve evaluation. Seventy-nine patients (77%) with successful test-stimulation underwent permanent implantation of the IPG. After a median follow-up of 42 months (range 2-102), 69 of the 79 patients (87%) had a steady reduction in incontinence symptoms (improvement of >50% compared to baseline). During follow-up, 22 IPG had to be removed (28%); in 10 patients, the whole device (electrode and IPG) was taken out (29%). Twelve patients underwent re-implantation of the IPG (17%). Reasons for the explantation of the IPG were infection (n=2), loss of clinical effect (n=10) and malfunction of the IPG (n=8). Only 2 IPG were replaced due to loss of battery function (planned). In our cohort of 103 patients, the unexpected removal of the IPG resulted in additional total cost of 274’830. This increased the cost per successful IPG implantation by 33% (Fig. 1). Conclusion: Although sacral nerve stimulation is a highly effective treatment for faecal incontinence, a considerable number of IPG have to be unexpectedly removed in the course of the treatment leading to substantial increase of the overall treatment costs. �� Figure 1 �� 38 swiss knife 2010; 7: special edition �� 43.3 Pelvic floor reconstruction with biomesh after abdominoperineal extendend excision for rectal cancer? V. Pioch, K. Wolff, L. Marti, C. Gingert, M. Adamina, F. H. Hetzer (St. Gallen) Objective: In order to achieve a better oncological outcome, the abdominoperineal extended excision (APE) has been recently described by Holmes for patients with advanced low rectal cancer The repair following such a large damage to the pelvic floor demands reconstructive surgery. We present our first experiences with a biological mesh (Permacol TM) for closure of the pelvic floor defect. Methods: The procedure began in supine position. After transabdominal mobilisation of the rectum, transsection of the sigmoid colon and performing a permanent descendostomy, the laparotomy is closed. The patient is then moved into jack-knife position. An extrasphincteric excision of the anal canal, including removing of the levator ani is performed. The coccyx’s tip is resected en bloc with the specimen. The rectosigmoid is removed through the perineum. Reconstruction of the pelvic floor is performed with a 1.5mm thick sheet of Permacol TM. A closed-suction drain is placed and the skin is closed. Results: From October to December 2009, 3 patients (2 male) of mean age 62.6 years (range 37 - 82), underwent extended APE. All patients had a very low rectal cancer, with a range of 2-4cm from the anal verge or with an infiltration of the pelvic floor, one in the context of ulcerative colitis. Two patients had neoadjuvant radiotherapy. Operation time ranged from 4h to 4h15min. No intraoperative complications occurred. Postoperatively a vaginal wound dehiscence occurred in one patient which required operative closure. Antibiotics for a perineal wound infection were needed in two patients. At last, all perineal wounds healed without removing the biomesh. Conclusion: Reconstruction of the pelvic floor after extended APE with a biomesh is a safe and straightforward procedure. While local infections occurred, the perineal wounds healed without removal of the biomesh. Although the three reported cases represent our hospital`s early experience, those results are encouraging and lack of any severe complications. 43.4 First experience with pudendal nerve stimulation for fecal incontinence S. Bock, P. Folie, K. Wolff, M. Adamina, L. Marti, F. H. Hetzer (St. Gallen) Objective: Sacral Nerve Stimulation (SNS) is an established treatment of refractory lower urinary tract and bowel dysfunction. For urological patients not yielding satisfactory results with SNS, Pudendal Nerve Stimulation (PNS) has recently been described and successfully tested. Given the sometimes unsatisfactory results after SNS in fecal incontinence (FI), we tested PNS for this indication. Methods: We performed PNS following a two stage technique as originally described by Spinelli et al. By modification of the introduction device, we developed a quick and easy-to-use technique for successful PNS-testing based on direct physical response. During the screening period (implanted tinned lead connected to an external neurostimulator), an improvement of symptoms of at least 50% was counted as success and lead to the implantation of a permanent neurostimulator. Results: From March to December 2009, we tested PNS in 8 female patients, median age 72 years (range 31-84). FI was due to sphincter defect in 2 patients, pelvic floor surgery in 5 and neurogenic factors in 4 (some patients with FI of multiple origins). Seven patients had failed SNS, in the other one SNS would not have been possible for anatomic reasons. In all patients a tinned lead could be placed successfully, with a median surgery time of 41 min (21-65) and a hospitalization of 1.5 days (1-4). After a median screening time of 16.5 days (0-39), 7 of 8 (87.5%) patients reported a success (Median reduction of symptoms 70% (range 30-90%)). Six patients had the permanent stimulator implanted; one patient is still waiting for permanent implantation due to an infection of the electrode. Conclusion: PNS is a successful minimal invasive procedure for patients who failed SNS in FI. Further studies are ongoing for refined patient evaluation and long-term follow-up. 43.5 Subtotal colectomy is afflicted with a significant lower anastomotic leak rate than left hemicolectomy in malignant left-sided colon obstruction S. A. Käser, P. Glauser, R. Dolanc, C. A. Maurer (Liestal) Objective: To compare two different one stage procedures for malignant left-sided colon obstruction; subtotal colectomy vs. left hemicolectomy. Methods: A retrospective cohort study over a period of 6 years was performed on all consecutive patients with malignant left-sided colon obstruction being treated at our surgical department (n=39). Obstruction was defined by failure to trespass the stenosis during endoscopy, by high-grade stenosis observed in contrast enema or by colonic dilatation (cecum >10cm, transverse colon >8cm, descending colon >6cm) in combination with serosal ruptures. Malignancy was verified by histopathological examination. Patients with a two-stage procedure were excluded (n=6). Three of these had rectal resections in the lower two thirds of the rectum requiring a protective ileostomy. Three two stage procedures were performed for other reasons. Thus 33 patients remained for further analyses. Group A had a subtotal colectomy (n=15) and group B (n=18) had a left hemicolectomy performed. Physiological severity score (PSS based on age, cardiac and respiratory morbidities, vital signs, blood tests), expected morbidity (POSSUM score based on PSS, operative severity, amount of procedures, blood loss, peritoneal soiling, malignancy, mode of surgery) and mortality (P-POSSUM based on POSSUM) were calculated. Wilcoxon ranksum test and Fisher’s exact test (2-tailed) were used for further analyses. Results: PSS was mean 25(SD 7.3) in group A vs. 21.2(SD 5.1) in group B (p=0.0815). ASA score was mean 3.1 in group A vs. 2.7 in group B (n=7 missing). Bowel dilatation was in present in 80%(SD 41.4) in group A vs. 39% (SD 50.2) in group B (p=0.05), Serosal ruptures was present in 47%(SD 51.6) in group A vs. 0% in group B (p=0.002). Expected morbidity (POSSUM) was 76.9%(SD 19.8) in group A vs. 64.1%(SD 20.4) in group B (p=0.049). Morbidity was 33.3%(SD 48.8) in group A vs. 55.6%(SD 51.1) in group B (p=0.296). Leakage rate was 0% in group A vs. 33.3%(SD 48.5) in group B (p=0.021). Expected mortality (P-POSSUM) was 21.3%(SD 25.6) in group A vs. 8.1%(SD 7.1) in group B (p=0.062). Mortality was 20%(SD 41.4) in group A vs. 16.7%(SD 38.3) in group B (p=1). (Tab. 1) Conclusion: In malignant left-sided colon obstruction, subtotal colectomy is afflicted with a significant lower anastomotic leak rate than left hemicolectomy, despite worse preoperative conditions in these patients.
�� Table 1. Health status, signs of advanced ileus, expected outcomes and real outcomes of patients with one stage procedures in malignant left-sided colon obstruction. 43.6 Early closure of ileostomy is associated with less postoperative nausea and vomiting M. Worni 1,2 , I. M. Schudel 2 , A. Witschi 1 , C. E. Kuehni 2 , D. Candinas 2 , B. Gloor 2 , U. Laffer 1 ( 1 Biel, 2 Berne) Objective: Temporary loop ileostomy is increasingly used in colorectal surgery, but little is known on the optimal time point for its closure. We compared postoperative morbidity, in particular nausea and vomiting, between patients with early and late closure of ileostomy. Methods: In a single centre retrospective analysis, data from all patients undergoing elective ileostomy closure between 1/2001 and 12/2008 were extracted from hospital charts, nursing records, operation reports and anaesthesia files, using a standardised data extraction sheet. The time that had elapsed between primary operation and ileostomy closure was grouped into quartiles: Q1 (early closure, 8-76 days), Q2 (77-103), Q3 (104-149) and Q4 (152-461 days). We included 87 men and 47 women, with a median age of 71 years (range 34-91). Indications for the primary operation were: carcinoma of the rectum (n=67, 50%), carcinoma of the sigmoideum (11, 8%), diverticulitis (32, 24%), rectal adenomas (7, 5%), other diagnoses (17,13%). Results: Ileostomy was closed after a median of 103 days (IQR 76-149; range 8-461). Nausea in the days following ileostomy closure occurred in 47% of patients with early closure and in 73%, 73% and 79% of patients in Q2, Q3 and Q4 respectively (p for trend 0.009). Vomiting occurred in 24% of patients with early closure and in 49%, 60% and 61% of patients in Q2, Q3 and Q4 respectively (p for trend=0.002). Adjusting for age, sex, primary diagnosis, previous operations, operating surgeon, duration of the operation and parastomal hernia, the Odds ratio (OR) for postoperative nausea, compared to patients with early closure (Q1), was 2.2 (95% CI 0.60-8.2) for patients in Q2, 4.1 (1.02-16.4) for patients in Q3 and 7.9 (1.8-34.9) for patients in Q4 respectively (p=0.0014). Adjusting for the same covariates, the OR for postoperative vomiting, compared to patients in Q1, was 2.1 (0.6-7.4) for patients in Q2, 6.0 (1.7-21.2) for patients in Q3 and 5.6 (1.5-20.5) for patients in Q4 respectively (p=0.0016). No significant differences were found for other postoperative problems and for length of hospitalisation. Conclusion: This study provides strong evidence that early closure of ileostomy is associated with significantly reduced postoperative nausea and vomiting. Because residual confounding can not be totally excluded, results should be confirmed in a randomised prospective trial. 43.7 What can we learn about senior colorectal surgery from 150 consecutive patients? S. Ostermann, P. Bucher, P. Gervaz, I. Neyroud, Ph. Morel (Geneva) Objective: Senior population (≥70y) represents 15-18% of Western population. As life expectancy increases and aging baby boomers are expected to double seniors in Europe by 2030-50. Thus more surgeries will have to be offered to these frail patients. Study aim was to assess results of senior colorectal surgery in term off postoperative morbidity & mortality and length of hospital stay. Methods: 152 consecutive senior patients who underwent elective colorectal surgery from 01/2008 to 11/2009 were entered in an institutional database. Median age was 80y (72-93y), M/F: 70/82, ASA ≥ 3: 44%. 461 treated comorbidities were recorded, with a median of 3 (0-6), including high BP (55%), ischemic/valvular/rhythmic cardiopathy (51%), stroke/CNS diseases (24%), chronic renal failure/ urinary incontinence (24%), hypercholesterolemia (22%), nutritional defect (19%), diabetes mellitus (17%), obesity (16%), vascular disease (15%), COPD (14%). Colorectal procedures were right colectomy 43, left colectomy 8, segmental/subtotal/total colectomy 4/4/2, sigmoidectomy 37, proctectomy 5, low anterior resection 17, colostomy 7, Hartmann reversal 17, abdomino-perineal amputation 8, with 20% performed by laparoscopy. Indications for surgery were adenocarcinoma (99), complicated diverticulitis (35), adenoma (13), volvulus (3), abscess (2). Results: Postoperative mortality and morbidity was 1.3% and 34% respectively, with 18/16% of general/surgical complications. Grade >= III complications were recorded in 10% (2 small bowel perforation, 1 cystic duct injury, 4 anastomotic leak/bleeding, 1 splenic rupture, 1 hernia incarceration, 1 pre-sacral abscess, 1 MOF, 1 respiratory failure and 3 myocardial infarction). Median hospital stay was 12 (3-69) days. 59% of patients were discharged to home. Actuarial survival rate was 93%, with a median follow-up of 10 (0.1-21) months. Conclusion: Elective colorectal surgery could be safely offered to senior patients but special attention must be applied their comorbidities which explain the higher complication rate in this frail population. As return to normal life is high in senior patients, shorter hospital stay and lower morbidity rate must be achieved to maintain their high level of independence. In this regard, a specifically senior fast-track surgery protocol is actually initiated in a randomized trial in our institution since November 2009. Research – Cancer 44 44.1 Short TCR signalling favours Th17 polarization of human naive CD4+ T cells R. A. Droeser, X. Huber, E. Trella, D. Frey, D. Oertli, M. Heberer, G. Spagnoli, G. Iezzi (Basel) Objective: A new subset of T-helper cells characterized by IL-17 production, thus termed Th17, has been recently described. Th17 cells have been recognized as critical mediators of anti-fungal immune responses as well as of autoimmune diseases. Moreover, recent evidence indicates that Th17 might also play a role in anti-tumour immunity. The parameters governing their development, however, are yet to be fully elucidated. We have investigated the role of the duration of T cell receptor (TCR) signalling on Th17 polarization of human naive CD4+ T cells in vitro. Methods: Naive CD4+ T cells from peripheral blood of healthy donors were activated by plastic-bound anti-CD3/CD28 antibodies for 24, 48 or 72 hours, under Th17 polarizing conditions, i.e. in the presence of IL-1beta and IL-6. After initial stimulation T cells were transferred to uncoated plates and expanded in the absence of stimulation up to seven days, before being evaluated for cytokine production. Results: Naive CD4+ T cells exposed to TCR-mediated stimulation for a period of 24 hours in the presence of IL-1beta and IL-6 efficiently underwent Th17 differentiation. However, when the TCR signalling was prolonged up to 72 hours, the percentages of IL-17 –producing cells as well as the amounts of IL-17 secreted by the expanded cell population were markedly reduced as compared to cells stimulated for 24 hours, although the cells had undergone a more extensive proliferation. The phenomenon appeared to be specific for the Th17 lineage. T cells exposed to prolonged stimulation under Th1 polarizing conditions, did not show any significant reduction in percentages of IFN-gamma-producing cells, as compared to T cells stimulated for shorter periods. The reduction in percentages of Th17 cells did not appear to be related to increased activation induced cell death, because no significant differences in percentages of apoptotic cells between 24 hour- and 72 hour-stimulated cells were observed. Conclusion: Our data indicate that a short exposure to antigenic stimulation in the presence of IL-1beta and IL-6 is sufficient to drive differentiation of human naïve CD4+ T cells towards Th17 phenotypes, whereas a prolonged TCR signalling is detrimental for Th17 polarization. Understanding the molecular bases of this phenomenon might offer the opportunity to target or trigger Th17 development for therapeutic interventions. 44.2 Expression of Programmed Death-1 in CD8+ T cells from patients bearing prostate cancer upon stimulation with common gamma-chain cytokines C. Mengus, C. Le Magnen, A. Bachmann, M. Heberer, G. Spagnoli, S. Wyler (Basel) Objective: Prostate cancer (PCA) is a leading cause of cancer death in men. Underlying immunosuppressive mechanisms in patients bearing benign prostate hyperplasia (BPH) and PCA are not fully clarified. We analyzed homeostatic proliferation of CD8+ T cells upon stimulation with common receptor gamma chain IL-2, IL-7 and IL-15 cytokines in PCA as compared to BPH patients. CD8+ T cells exhaustion was assessed by evaluating Programmed Death-1 (PD-1) receptor and its ligand PD-L1 expression in PBMC and tissue infiltrating CD8+ T cells from PCA and BPH patients. Methods: 62 BPH and 84 PCA patients were enrolled. Gene expression was quantified by Real-Time PCR. T cell proliferation was evaluated by CFSE dilution. CD132, CD122, PD-1 and PD-L1 expression were assessed by flow cytometry. Results: IL-7 and IL-15 gene expression were significantly increased (p=0.024 and p=0.031, respectively) in PCA tissues (n=60) as compared to BPH (n=34). No significant differences were observed for IL-2 gene expression. A trend towards a lower CD8+ T cell proliferation in response to IL-15 was detectable in PCA as compared to BPH patients. No differences were observed for the expression of the alpha chain and the common-gamma (CD132) and -beta (CD122) chains of homeostatic cytokines receptor in CD8+ T cells from BPH (n=16) and PCA (n=13) patients. Urged by these findings, we addressed the expression of PD-1 and its ligand in CD8+ T cells from BPH and PCA patients. In BPH (n=7) and PCA (n=7), percentage of CD8+PD-1+ and of CD8+PD-L1+ cells are increasing upon culture with homeostatic cytokines. In freshly isolated CD8+ T cells, PD-1 and PD-L1 expression were similar in BPH (n=22) and PCA (n=32) patients. A large majority of CD8+ T cells infiltrating BPH (n=9) or PCA (n=7) tissues (83±22% and 88±17%, respectively) were PD-1+, whereas PD-L1 was expressed in 51±43% and 37±39% of infiltrating CD8+ T cells in BPH and PCA, respectively. Conclusion: Taken together these data indicate that CD8+ T cells from PCA patients display a decreased responsiveness to IL-15 homeostatic cytokines as compared to BPH. Interestingly, high percentages of peripheral blood CD8+ T cells express PD-1 in BPH and PCA patients. Notably, PD-1 and its ligand are highly expressed in tissue infiltrating CD8+ T cells in BPH and PCA patients, thus raising the issue of the role of T cells exhaustion in PCA. swiss knife 2010; 7: special edition 39
Page 1 and 2: Abstracts 97. Jahreskongress der Sc
Page 3 and 4: Der Jahreskongress der Chirurgische
Page 5 and 6: Abstracts Session Topic Page 02 Vis
Page 7 and 8: Visceral Surgery - Cholecystitis &
Page 9 and 10: performed were recorded. Descriptiv
Page 11 and 12: avec délai dans le diagnostic, ang
Page 13 and 14: group (conventional: n=13, RS=1.8 +
Page 15 and 16: time-efficient all-in-one 3D visual
Page 17 and 18: (CHI=54 [6.49%]; SWI=27[4.98%]) wer
Page 19 and 20: Conclusion: Both procedures markedl
Page 21 and 22: 22.7 Transplantation of kidneys fro
Page 23 and 24: of the remaining 40 patients with a
Page 25 and 26: and 6/2009 and were prospectively f
Page 27 and 28: Conclusion: In our patient cohort,
Page 29 and 30: plantation. With the introduction o
Page 31 and 32: Results: SLN negative patients were
Page 33 and 34: Conclusion: This is the first study
Page 35 and 36: were grouped into four age groups a
Page 37: gain up to the 20 th procedure (Fig
Page 41 and 42: normal angiogenesis induced by cell
Page 43 and 44: 52.4 Sham-feeding of patients with
Page 45 and 46: Methods: Erfasst wurden Aggressions
Page 47 and 48: Conclusion: Pharmacological inhibit
Page 49 and 50: 54.19 Gene chip analysis of A20 exp
Page 51 and 52: 55.10 Optimized intrapleural cispla
Page 53 and 54: 62.7 Posttraumatic symptomatic cyst
Page 55 and 56: Conclusion: Only patients older 75
Page 57 and 58: no sign of occlusion. No further th
Page 59 and 60: packing as part of damage control s
Page 61 and 62: sonalführung und werden auch in de
Page 63 and 64: Figure 3 Figure 2 Figure 4 71.2 Tec
Page 65 and 66: formed 5 months later, again with a
Page 67 and 68: 99.16 3-D endo-stomal ultrasound (
Page 69 and 70: tional recanalization. Conclusion:
Page 71 and 72: 99.37 Extended Clavien-Dindo classi
Page 73 and 74: ial colitis was excluded by stool c
Page 75 and 76: 99.55 Complexes de von Meyenburg(ha
Page 77 and 78: 99.64 Traumatic abdominal wall hern
Page 79 and 80: 99.75 Isolated dorso-medial disloca
Page 81 and 82: FRAGMIN ® DER ERFAHRENE WEGGEFÄHR
Page 83 and 84: Kalbermatten Daniel, PD Dr., CHUV C
Page 85 and 86: Meyer Antoine, Dr., Hôpital canton
Page 87 and 88: Covidien Switzerland Limited multip

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