[The colocutaneous fistula - a rare complication of percutaneous endoscopic gastrostomy]. / Die kolokutane Fistel - eine seltene Spätkomplikation nach PEG-Anlage.

HISTORY AND ADMISSION FINDINGS: A 43-year-old woman with spastic tetraparesis, mental retardation and long-term tube feeding was admitted for a replacement of the PEG tube, 15 months after placement and regular use of her first feeding tube. New problems had occurred with local infection and a suspected leakage. The gastrostoma showed a local erythema and increased secretion of putrid fluids, furthermore a tendency to diarrhea had developed. Otherwise the abdomen was inconspicuous. INVESTIGATIONS: All routinely achieved blood tests were normal. Gastroscopy revealed a mucosal scar with a small fistula instead of the expected tip of the PEG tube. A CT scan demonstrated displacement of the tip into the transverse colon. TREATMENT AND COURSE: The displaced PEG tube was removed by colonoscopy. After laparoscopic occlusion of the colocutaneous fistula with a surgical stapler and clearing of further adhesions a new PEG was inserted endoscopically during the same operation with laparoscopic guidance through the pneumoperitoneum. CONCLUSION: The development of a colocutaneous fistula as a result of an unperceived perforation is a rare complication of a PEG placement. Despite of the notable mechanism that the tip of the tube erodes the gastric wall and penetrates into the adjacent colon, the clinic is often oligosymptomatic and can easily been missed.

The "winged" circular anal dilator in stapled hemorrhoidectomy.

Stapled hemorrhoidectomy is gaining popularity worldwide. One problem that is often encountered is difficulty with insertion of the circular anal dilator because of very protuberant and fatty buttocks and a narrow interischial tuberosity distance. We describe a modification of this device for easier introduction in such patients.

[The "buried bumper syndrome"--a rare complication of percutaneous endoscopic gastrostomy]. / Das Buried Bumper-Syndrom--Eine seltene Komplikation nach perkutaner endoskopischer Gastrostomie (PEG).

The buried bumper syndrome is a rare complication of percutaneous endoscopic gastrostomy (PEG). Hereby the PEG bumper is overgrown by hypertrophic gastric mucosa and embedded into the gastric wall. This is probably a consequence of enforced tightening of the PEG tube causing an ulcer in the gastric mucosa. Endoscopically the bumper is not visible anymore. The symptoms of the buried bumper-syndrome are a poorly transporting PEG tube, a PEG tube that cannot be mobilised, secretion along the tube and upper abdominal pain. Most often an endoscopic approach to remove the bumper is successful. If not, the operative removal of the plate is necessary. After endoscopic removal of the tube an endoscopic replacement of a PEG tube is technically possible.

[Transanal endoscopic microsurgery--experiences at the Zurich University Hospital]. / Die transanale endoskopische Mikrochirurgie--Erfahrungen am USZ.

The advantages of TEM (transanal endoscoic microsurgery) are minimally invasive, exact and full thickness excision of tumors in the rectum and a very low morbidity with excellent comfort for the patient. In a retrospective study all transanal endoscopic operations at Zurich University hospital in the last 5 years have been analyzed (n = 18). 11 adenomas and 5 carcinomas of the rectum have been resected with TEM (one mucosectomy, 16 full wall resections and one segmental resection of the rectum). In the group of the carcinomas there were four preoperatively known carcinomas, one T1 carcinoma was discovered postoperatively in the analyzed tissue. Among the four known carcinomas was one T1 carcinoma, two T2 carcinomas (one of them was thought to be a T1 preoperatively) and one T3 carcinoma. One patient with T2 carcinoma wanted specifically a minimally invasive procedure, the other one with T2 carcinoma was an older patient who didn't qualify for laparotomy. The patient with T3 carcinoma also had a malignant lymphoma. The operation was tolerated well by all the patients. There was one case of peritoneal perforation treated laparscopically and one case of postoperative bleeding. An incontinence of gas in one patient disappeared after 3 months. There was no adjuvant treatment in the group of the T1 carcinomas. One patient with a postoperative T2 carcinoma did not want a chemotherapy. The other two patients with T2 and T3 were polymorbid. Among the resected adenomas there was no case of recurrence. One T2 carcinoma recurred. These results show that transanal endoscopic microsurgery (TEM) is an excellent technique to treat ademomas and T1 carcinomas of the rectum with the advantages of full thickness excision under good vision, a minimal rate of recurrence and maximal patient comfort. The indications for transanal microsurgery are rare. The techically demanding operation is not always simple and should be performed in larger centers only.

[Socioeconomic advantages of laparoscopic cholecystectomy]. / Die sozioökonomischen Vorteile der laparoskopischen Cholezystektomie.

A cohort of 100 consecutive patients cholecystectomized by laparoscopy was compared retrospectively under diverse socio-economic viewpoints to a cohort of 100 patients that underwent conventional cholecystectomy by means of the matched pair procedure. Laparoscopic cholecystectomy does not only combine enhanced comfort and less postoperative pain without loss of safety for the patient, but also offers objectively attainable socio-economic advantages in comparison to conventional, open cholecystectomy. Operation time was not prolonged in laparoscopic cholecystectomies. Patients stayed less long in the hospital and regained fitness for work earlier. The reduced time of inability to work could be lowered in the total cohort by 36% and was thus of great importance, particularly for working people. Costs saved by reduced time of hospitalization by laparoscopic cholecystectomy were balanced by higher additional costs of this procedure. Altogether, total costs for health insurance and other insurances induced by laparoscopic cholecystectomy were lower compared to those of conventional operation.

[The need for blood transfusions in elective colon surgery--is preoperative autotransfusion useful?]. / Der Bedarf an Bluttransfusionen bei elektiven Koloneingriffen--Ist die präoperative Eigenblutspende sinnvoll?

All elective surgical procedures of the colon from 1992-1994 at Kreisspital Männedorf were analyzed retrospectively. The goal of this study was to find out if a preoperative autologous blood donation before elective colon surgery is useful and if so to determine the amount of blood to be donated. In 87 surgical procedures of the colon, the use of homologous blood transfusions was studied. The need for transfusion was highest in abdominoperineal resection with 6.8 (+/- 4.45) units and lowest in sigmoid resections with 0.68 (+/- 0.88) units. The estimated intraoperative blood loss was 868.67 (+/- 732.54) ml and 1.8 (+/- 2.6) units of homologous blood were transfused. The need for transfusion depended on the preoperative hemoglobin, the estimated intraoperative blood loss and the duration of the operation. We concluded that a preoperative donation of autologous blood before sigmoid resection is unnecessary. For all other colon resections with malignant or benign disease autologous blood transfusion is useful provided the patient meets the requirements for donation. A donation of 2 units of autologous blood is sufficient. With a preoperative hemoglobin value. > or = 11 g/dl and an estimated intraoperative blood loss < or = 1000 ml or an operation time < or = 150 min. the need for additional transfusion with homologous blood is minimal.