Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy.

BACKGROUND: Paralysis of the diaphragm is a severe complication of cardiothoracic surgery carrying significant morbidity and mortality. This study demonstrates a novel minimally invasive technique for treatment of phrenic nerve injuries presenting with symptomatic eventration of the diaphragm. It also presents long-term results of three patients treated with this operation. METHODS: Chest x-ray proved eventration of the left diaphragm in all patients. Two patients required treatment due to prolonged respirator therapy/assisted ventilation for 4 weeks after cardiac surgery. One patient suffered from progressive dyspnea caused by increasing left-sided diaphragmatic elevation and underwent surgery 2 years after cardiac surgery. In all cases, a minimally invasive abdominal approach was chosen. During surgery the dome of the diaphragm was pulled down via three percutaneously inserted retention stitches. This resulted in two or three folds of the diaphragm located within the abdomen. These diaphragmatic folds were subsequently tightened using 12 to 15 unresorbable sutures with extracorporally prepared knots. Surgical as well as long-term follow-up results are presented of all patients and a review of the current literature is provided. RESULTS: Mean operating time was 203 min; mean intraoperative blood loss was 130 ml. No major complications occurred during surgery or the postoperative period. At a median follow-up of 72 months no recurrence was observed. CONCLUSIONS: Laparoscopic diaphragmatic plication provides excellent relief of symptoms caused by diaphragmatic paralysis. There is no perioperative morbidity, and hospital stay is short. The laparoscopic approach, therefore, is an attractive surgical alternative for the treatment of phrenic nerve palsy and should be considered in all suitable patients.

Techniques and results of esophageal cancer surgery in Germany.

AIMS: This study evaluated the techniques and short-term results of surgical treatment for esophageal cancer in Germany by a nationwide representative survey. METHODS: In 2000 a questionnaire including 63 structured items concerning indication, technique, number of procedures, complications, and hospital mortality was sent to 308 randomly selected general, gastrointestinal, and thoracic surgeons and all university hospitals in Germany (20% of all surgeons). The response rate was 76% ( n=234). RESULTS: In 1999 the 56 participating hospitals performed approximately 370,000 procedures, including 1,677 operations for esophageal diseases, including 891 esophagectomies, 706 for esophageal cancer, 285 for cancer of the cardia. Gastric interposition was the most common technique to restore alimentary tract continuity (86%). Interposition of the colon (ascending colon 64%) is a common procedure only in 22 centers, indicating that experience with this means of esophageal reconstruction is limited. There were no significant differences in complication and mortality rates between gastric transposition and colon interposition. The overall complication rate was 61%, with 36% after gastric interposition and 42% after colon interposition. Anastomotic leakages occurred in 12% and 15%, respectively, and the rate of graft necrosis was 3% in both groups. Hospital mortality was 8% with gastric transposition and 11% with colon interposition. Mean postoperative hospital stay was 24 days. CONCLUSIONS: This study indicates that gastric transposition is frequently used for reconstruction after esophageal resection for malignant disease. It appears that the colon is not as accepted as the stomach for reconstruction, although the reported complication rates compare well with those reported after gastric transposition. This study allows a realistic evaluation of the overall risk of these surgical techniques.

[Indications, techniques and results of laparoscopic surgery for diaphragmatic diseases]. / Indikation, Technik und Ergebnisse der laparoskopischen Zwerchfellchirurgie.

Eleven patients with congenital, traumatic and functional extrahiatal diaphragmatic lesions are reported. Since 1991 two patients with acute, two patients with old ruptures of the diaphragm and one patient with a Morgagni-Larrey-hernia were successfully treated by laparoscopic direct suturing. In two other patients with Morgagni hernias we used a polypropylene mesh for closure of the defect. One procedure was performed in a patient with symptomatic congenital dysplasia of the diaphragm with aplasia of the pericard. Laparoscopic plication of the diaphragm was performed in three symptomatic patients with phrenic nerve palsy after cardiac surgery. The intra- and postoperative course was uneventful in all cases. During a median follow-up of 60 months there was no recurrence. Therefore the laparoscopic technique is an effective and attractive alternative for treatment of these diseases.

[Management of common bile duct stones--Results of a nationwide survey with analysis of 8 433 common bile duct explorations in Germany]. / Management der Choledocholithiasis - Umfrageergebnisse und Analyse von 8 433 Gallengangsrevisionen in Deutschland, Germany.

BACKGROUND: Aim of this study was the evaluation of the management of choledocholithiasis and outcome of laparoscopic as well as open cholecystectomy in Germany. METHODS: A written questionnaire was sent to 449 randomly selected German surgeons annually from 1991 to 1994 and additionally to all German university hospitals until 1998. RESULTS: A total of 98 482 operations for gallstone disease including 86 485 cholecystectomies (non-university hospitals 1991-1993: n = 60 246, university hospitals 1991-1996: n = 26 239) and 8 433 common bile duct (CBD) explorations (non-university hospitals: n = 6 919, university hospitals: n = 1 514) with or without cholecystectomy were reported. The overall complication rate for CBD explorations was 13.2 % (non-university hospitals) and 15.1 % (university hospitals), the overall hospital mortality rate was 0.64 % (non-university hospitals) and 0.58 % (university hospitals, n. s.). When choledocholithiasis was suspected, in 1998 all university hospitals used a two-stage management with preoperative ERC. In case of diagnosed isolated choledocholithiasis 93 % usually chose an endoscopic approach. When simultaneous cholecysto-choledocholithiasis was diagnosed preoperatively 86 % of the university hospitals used a two-stage management with preoperative ERC and stone extraction and secondary cholecystectomy (1991: 45 %). The percentage of CBD explorations decreased continuously from 7.4 % in 1991 to 3.8 % in 1996 (p < 0.01). CONCLUSION: These results allow for the estimation of frequency and overall risks in surgical therapy of CBD stones. At the moment, laparoscopic CBD exploration does not play a significant role in Germany. Data show a trend to the two-stage "therapeutical splitting" with lower complication rates.