Prevalence of postcholecystectomy symptoms: long-term outcome after open versus laparoscopic cholecystectomy.

After cholecystectomy a certain number of patients continue to suffer from abdominal symptoms or develop such symptoms postoperatively. The aim of this study was to compare the prevalence of postcholecystectomy symptoms with open cholecystectomy during the prelaparoscopic era and those with laparoscopic cholecystectomy 4 years after introduction of the laparoscopic technique. Between July 1988 and June 1989 a total of 163 consecutive patients with elective open cholecystectomy and between September 1994 and August 1995 a total of 234 consecutive patients with elective laparoscopic cholecystectomy were prospectively evaluated using a standard questionnaire about preoperative symptoms, diagnostic modalities, and intraoperative findings. After a minimum of 12 months the patients were interviewed by telephone. Since the introduction of the minimal invasive technique the number of cholecystectomies performed at our institution increased. There was no significant difference in the prevalence of postcholecystectomy symptoms found after the open procedure compared with laparoscopic cholecystectomy: 90% of patients after open and 94% after laparoscopic cholecystectomy had no or only minor symptoms.

The learning curve of laparoscopic cholecystectomy and changes in indications: one institutions's experience with 2,650 cholecystectomies.

PURPOSE: In a prospective series of 2,650 consecutive patients undergoing cholecystectomy, we analyzed the learning curve since the introduction of laparoscopic cholecystectomy (LC) in terms of operating time, conversion rate, morbidity, mortality, and consequent changes in indications for either laparoscopic or open cholecystectomy (OC). PATIENTS AND METHODS: Between July 1990 and June 1997, LC was performed in 1,929 patients (73%), 203 of whom (7.5%) had to be converted to OC, while 518 patients (19.5%) had primary OC. Patients having LC were predominantly female, younger, with less comorbidity and less complicated gallstone disease than patients having OC. RESULTS: Barring a learning curve during the first 6 months of LC, operating time remained constant at an average of 71 minutes while operating on ever more complex pathologies. The conversion rate decreased from 9.4% to 6.7% during the 7-year period. A relatively constant team of surgeons with growing experience as well as constantly improving technical equipment allowed the complication rate to remain low. The total morbidity of LC was 2.5% (0.1% bile duct injury), that of conversions 5%, and that of OC 12.5%. The mortality was 0 for LC, 0.5% for conversions, and 1% for OC. CONCLUSION: The indications for primary OC decreased from 50% to 8.5% and the indications for LC could be broadened over the years.

Effect of HMG-CoA reductase inhibitors on extracellular matrix expression in human vascular smooth muscle cells.

Clinical studies have shown that treatment with 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors can stabilize atherosclerotic plaques and slow their progression. One determinant of plaque stability and size is the composition of the vascular extracellular matrix. The aim of this study was to evaluate the effects of different HMG-CoA reductase inhibitors on the expression of major components of the vascular extracellular matrix in smooth muscle cells. Cultured human vascular smooth muscle cells were incubated for 24-72 h with the HMG-CoA reductase inhibitors lovastatin (1-50 micromol/L), simvastatin (0.05-20 micromol/L), and pravastatin (1-100 micromol/L). RNA expression of the extracellular matrix proteins thrombospondin-1, fibronectin, collagen type I, and biglycan as well as expression of the cytokine TGF-beta1 was determined by Northern blotting. Extracellular matrix protein secretion was visualized by immunofluorescence. In addition, cell proliferation and viability were measured using BrDU-ELISAs, MTT-tests, and direct cell counting. Expression of thrombospondin-1 was significantly decreased after 24 h incubations with lovastatin in concentrations as low as 1 micromol/L. Coincubation with the cholesterol precursor mevalonate completely reversed this effect. The downregulation of thrombospondin-1 expression occured in the same concentration range that also inhibited cell proliferation. In contrast, lovastatin did not affect expression of fibronectin, whereas collagen type I and biglycan expression decreased only after long incubations with high, toxic lovastatin concentrations. Simvastatin, but not the very hydrophilic compound pravastatin, had a similar effect on extracellular matrix expression as lovastatin. In summary, lovastatin and simvastatin predominantly decrease the expression of the glycoprotein thrombospondin-1, which is functionally associated with smooth muscle cell migration and proliferation. In contrast, expression of plaque-stabilizing extracellular proteins such as collagen type I and biglycan are much less affected.

Mutations in the pilz group genes disrupt the microtubule cytoskeleton and uncouple cell cycle progression from cell division in Arabidopsis embryo and endosperm.

Organised cell division and expansion play important roles in plant embryogenesis. To address their cellular basis, we have analysed Arabidopsis abnormal-embryo mutants which were isolated for their characteristic phenotype: mutant embryos are small, mushroom-shaped ("pilz") and consist of only one or few large cells each containing one or more variably enlarged nuclei and often cell wall stubs. These 23 mutants represent four genes, PFIFFERLING, HALLIMASCH, CHAMPIGNON, and PORCINO, which map to different chromosomes. All four genes have very similar mutant phenotypes although porcino embryos often consisted of only one large cell. The endosperm did not cellularise and contained a variably reduced number of highly enlarged nuclei. By contrast, genetic evidence suggests that these genes are not required for gametophyte development. Expression of cell cycle genes, Cdc2a, CyclinA2 and CyclinB1, and the cytokinesis-specific KNOLLE gene was not altered in mutant embryos. However, KNOLLE syntaxin accumulated in patches but no KNOLLE-positive structure resembling a forming cell plate occurred in mitotic cells. A general defect in microtubule assembly was observed in all mutants. Interphase cells lacked cortical microtubules, and spindles were absent from mitotic nuclei although in rare cases, short stubs of microtubules were attached to partially condensed chromosomes. Our results suggest that the cellular components affected by the pilz group mutations are necessary for continuous microtubule organisation, mitotic division and cytokinesis but do not mediate cell cycle progression.

[CA19-9 has no value as a tumor marker in obstructive jaundice]. / CA19-9 hat bei Verschlussikterus als Tumormarker keine Bedeutung.

In the differential diagnosis of pancreatic cancer, CA19-9 appears to be the most sensitive and specific marker currently in use. In the absence of jaundice and at levels greater than 1000 U/ml, the specificity is almost 100%. Levels higher than 1000 U/ml are very uncommon for benign diseases. We report a case of obstructive jaundice due to an impacted stone in the common bile duct with cholangitis, where a CA19-9 level of 61,800 U/ml prompted suspicion of a malignant cause. After treatment the CA19-9 returned to a normal level. One year postoperatively neither abdominal ultrasound nor CT-scan showed any sign of intraabdominal malignancy. Reviewing the literature, we conclude that even very high levels of CA19-9 in cases with obstructive jaundice can be caused by benign diseases. Unlike other tumour markers (alpha-foetoprotein, carcinoembryonic antigen), where exceedingly high levels are definitely caused by malignancy, high levels of CA19-9 can be caused by benign obstructive jaundice. In such cases CA19-9 is useless as a tumour marker. The biliary obstruction must be treated successfully and more diagnostic procedures or even laparotomy performed, to exclude malignancy or treat a benign disease.

[Increasing frequency of bariatric surgery interventions since replacement of gastroplasty by laparoscopic gastric banding in the treatment of morbid obesity]. / Steigende Frequenz bariatrisch-chirurgischer Eingriffe seit Ersatz der Gastroplastik durch das laparoskopische Magenband zur Behandlung der morbiden Adipositas.

Between 1984 and 1996 we performed a Mason gastroplasty for the treatment of morbid obesity: 14 patients (average age 40 (26-48) years, body mass index (BMI) 48 (37-71) kg/m2, excessive body weight 67 (41-116) kg). Since the end of 1996 we now apply adjustable laparoscopic gastric banding (lab band): 73 patients (average age 39 (22-64) years, BMI 45 (32-69) kg/m2, excessive body weight 66 (41-116) kg). We compared the early and late results of both methods. Early results: no relevant morbidity or mortality for neither method. Late/intermediate results: reoperation rate for both methods 15%. After an average of 3.7 years the excessive body weight loss (EWL) for gastroplasty was 54 (22-96)%. The EWL after lab band for 24 patients after 12 months was 47 (11-127)% and for 8 patients after 18 months 51 (28-139)%. Since the introduction of the lap band the number of bariatric operations has greatly increased. Nevertheless, the perioperative complication rate has remained low, and the long-term outcome is similar for both methods.

[Hemorrhagic pseudocysts and pseudoaneurysms in pancreatitis. Diagnosis and therapy]. / Hämorrhagische Pseudocysten und Pseudoaneurysmen bei Pankreatitis. Diagnostik und Therapie.

Acute hemorrhage from pseudocysts and pseudoaneurysms is a threatening complication of chronic pancreatitis. Whilst surgical intervention still has high perioperative mortality (16.8%), transcatheter arterial embolization is becoming more frequently used for suitable cases and appears to have lower mortality (6.1%). We report on six patients treated in our unit. Four of them underwent primary surgical treatment, the other two were treated by embolisation. One of the latter patients subsequently required laparotomy for further treatment. All six patients survived. Comparing the literature covering the periods between 1951 and 1981 and between 1982 and 1996, transcatheter embolisation seems to be valuable in controlling this type of bleeding, thereby reducing mortality.

[Postcholecystectomy complaints one year after laparoscopic cholecystectomy. Results of a prospective study of 253 patients]. / Postcholecystektomiebeschwerden ein Jahr nach laparoskopischer Cholecystektomie. Ergebnisse einer prospektiven Untersuchung von 253 Patienten.

AIMS: We studied the nature and frequency of symptoms 1 year after laparoscopic cholecystectomy in order to define pre- and perioperative factors that influence the long-term outcome. METHOD: Between September 1994 and August 1995 we prospectively evaluated 268 patients undergoing laparoscopic cholecystectomy using a standard questionnaire. After an average of 16 months (12-25 months) the patients were asked about their symptoms using a similar questionnaire by telephone or were followed up clinically if necessary. RESULTS: In the long-term follow-up the severity of the symptoms according to the Visick score were: Visick I (no symptoms): 164 patients (65%); Visick II: 72 (28%); Visick III: 12 (5%); Visick IV: 5 (2%). The aetiologies of the postcholecystectomy syndrome were: residual stones 1%, subhepatic liquid formation 0.8%, incisional hernia 0.4%, peptic diseases 4%, wound pain 2.4%, functional disorders 26%. Patients with typical or atypical symptoms preoperatively showed no difference in the outcome 1 year after laparoscopic cholecystectomy. Neither did the number and location of laparotomies prior to cholecystectomy or the gallbladder perforation or loss of stones intraoperatively influence the severity of the postcholecystectomy symptoms. CONCLUSIONS: One year after laparoscopic cholecystectomy 93% of the patients have no or only minor abdominal symptoms. Neither the number and location of the laparotomies prior to cholecystectomy nor the loss of gallstones intraoperatively have an impact on the long-term result.

[The Vollmer hook--a new abdominal retractor]. / Der Vollmer-Haken--eine neue Bauchsperre.

Here, we present the so-called "Vollmer retractor", which can be fixed on to the operating table. It allows an optimal transference of the traction force on to the border of the wound, both in upper and lower abdominal interventions. In this way, as shown by our recent experience, we gain an optimal view of the subdiaphragmatic area and into the small pelvis.

[Results of anal sphincteroplasty in fecal incontinence--significance of intra-anal ultrasound imaging]. / Resultate der analen Sphinkterplastik bei Stuhlinkontinenz--Bedeutung der endoanalen Sonographie.

UNLABELLED: The aim of the study was to evaluate the clinical, manometric and endosonographic results of overlapping sphincteroplasty for traumatic sphincter defects documented by endosonography. PATIENTS AND METHOD: We performed an overlap repair in 10 women aged 34 to 68 with fecal incontinence due to sphincter defects after obstetric (n = 8) or iatrogenic (n = 2) trauma. The fecal incontinence was graded using the Miller Score (0-18 points). Manometry and endosonography were done pre- and postoperatively. The mean follow-up time was 17 months (6-25 m.). RESULTS: Perioperative morbidity was low: one temporary colostomy was necessary due to an anal fistula. Eight out of 10 patients were satisfied with the result. The incontinence grade fell from an average of 14 points (8-17 points) preoperatively to 5 (0-12 points) postoperatively. The mean resting pressure increased from 36 to 41 mmHg, the voluntary contraction from 48 to 59 mmHg. Endosonography allowed the precise localization of the defect before operation and the sphincteroplasty could be visualized after operation in all the patients. CONCLUSIONS: The overlapping sphincteroplasty improved fecal incontinence successfully in 9 of 10 patients with posttraumatic sphincter defects. Endosonography is very useful in localization of the sphincter defect and documentation of the performed sphincteroplasty.

[Meckel lithiasis. A rare complication of a Meckel's diverticulum]. / Meckellith. Seltene Komplikation eines Meckel-Divertikels.

HISTORY AND CLINICAL FINDINGS: Acute abdominal pain, radiating to the right and left lower abdomen with pain on abdominal pressure developed in a 67-year-old man. There were questionable signs of peritonitis. INVESTIGATIONS: Leukocytosis (20,000/microliter) and a high level of C-reactive protein (177 mg/l) were found. Ultrasound and computed tomography were suggestive of a stone in a Meckel's diverticulum. TREATMENT AND COURSE: This diagnosis was confirmed at surgery and there were no other abnormalities. The diverticulum with stone was resected and the patient made an uneventful recovery. CONCLUSIONS: A stone in a Meckel's diverticulum, although rare, should be included in the differential diagnosis of acute abdomen with radiological evidence of calcification in the lower abdomen. The possibility of this rare complication raises the question of prophylactic resection of Meckel's diverticulum, even when it is merely an incidental finding.

[11 cases of anal Bowen's disease]. / 11 Fälle von analem M. Bowen.

Bowen's disease of the anal region is a rare, slow-growing, intraepidermal squamous-cell carcinoma (carcinoma in situ). If surgical excision is incomplete, there is a risk of subsequent development of malignancy and metastasis. Between 1980 and 1995 we treated 11 patients (8 female, 3 male) with anal Bowen's disease. The mean age was 55 (34-75) years. The main reason for excision was: pain (4), itching (3), bleeding (3) and a disturbing lump (3). The intraoperative findings were in all cases a lesion at the anocutaneous line: perianal or intra-anal tumor (6), erosion (2) or ulceration (2) as well as lichenoid lesion (4) or hyperpigmentation (3). The procedure was excision of the lesion in 10 cases. Only in one case was a biopsy taken. 3 patients had to be operated on a second time for reasons of radicality. 5 years after primary diagnosis, one patient developed a recurrent invasive squamous-cell carcinoma and had to undergo perineo-abdominal rectum amputation with postoperative radiotherapy (2 years after operation). Only one patient underwent a biopsy, which produced the diagnosis of invasive squamous-cell carcinoma. He underwent combined chemo-radiotherapy. The symptoms of anal Bowen's disease are unspecific and the clinical findings are uncharacteristic. The recommended therapy is complete surgical excision. With complete excision no recurrences do occur.

[Surgery of inguinal hernia in Switzerland in 1994. A survey of 142 teaching clinics in Switzerland]. / Leistenhernienchirurgie in der Schweiz 1994. Eine Umfrage an 142 Ausbildungskliniken in der Schweiz.

With a response rate of 60.6% to a questionnaire sent out in 1994 it is possible to give an overview of the situation in hernia surgery at the 142 surgical clinics of Switzerland. In general, regional anesthesia is the preferred method (67.4%). Together, Shouldice repair and fascia transversalis repair cover over 90% of the repair techniques in primary hernias. In recurrent hernias the same techniques dominate (70.2%) a large spectrum of different operation methods; implantation of foreign materials is rare (5.9%). Only 4.5% of all Swiss surgical clinics have some experience with endoscopic hernia surgery.

[Preperitoneal prosthesis implantation in surgical management of recurrent inguinal hernia. Retrospective evaluation of our results 1989-1994]. / Die präperitoneale Protheseneinlage zur operativen Versorgung der Rezidivleistenhernie. Retrospektive Beurteilung unserer Resultate von 1989-1994.

Recurrent inguinal hernia represents a great problem in surgery given the frequency of this operation, with a recurrence rate of 0.5-8%. Re-recurrence after repair without implantation of a prosthesis occurs in 1-23% of cases. We analyzed our results of patients with recurrent inguinal hernia, operated according to the method of Stoppa. Between 1989 and July 1994 there were 58 operations upon 55 patients with an average age of 65 years, 79% of whom had unilateral and 21% bilateral hernias. 89% of all patients underwent surgery because of a recurrent inguinal hernia. A Marlex mesh was used in 79% of the case. All patients were followed up (mean 35 months, minimum 12 months). Early complications consisted in one hematoma (1.7%), which had to be drained, as well as one early recurrence (1.7%). No infections were observed. The overall recurrence rate was 12%. However, 60% of all recurrences occurred in the few first years after introduction of this technique at our clinic; with growing number of operations and experience with Stoppa's technique, we obtained a recurrence rate of 6-7% per year. In our opinion, supported by the results of other studies, Stoppa's technique is a successful method in the treatment of recurrent inguinal hernia.

[Treatment of rectum adenoma. Retrospective study of the treatment of inpatients (1987-1991)]. / Die Behandlung des Rektumadenoms. Retrospektive Untersuchung stationär behandelter Patienten (1987-1991).

In carrying out an evaluation prior to acquisition of equipment for transanal endoscopic microsurgery (TEM), we wished to examine current concepts in the treatment of rectal adenoma, i.e.: What form of surgery was chosen in relation to the dimension and localization of the adenoma? Should the indications for the particular procedure be changed to render it less invasive? Should the new endoscopic surgical method TEM be introduced? 134 inpatients covering a 5-year period were evaluated. We analyzed the correlation between localization of the adenoma in the rectum (42% low, 22% middle, 36% high position), diameter of the tumor (37% < 2 cm, 38% 2-4 cm, 11% 4-6 cm, 10% > 6 cm) and type of surgery (endoscopic 27%, transanal 45%, anterior resection 25%). We found a high percentage of anterior resections in the middle rectum which could be reduced by introduction of the less invasive TEM. 29 (22%) of our patients could have been treated with TEM.