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.

[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.

[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.

[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.

[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.

[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.

[Initial results with laparoscopic fundoplication]. / Erste Erfahrungen mit der laparoskopischen Fundoplicatio.

17 patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease not responding to medical treatment. Conversion to laparotomy was necessarily due to large paraesophageal hiatus hernia (3) or severe peri-esophagitis (1) in 4 patients. There was no perioperative morbidity or mortality. At 3 months all patients were symptom-free. Esophageal manometry revealed a rise in mean lower esophageal sphincter pressure from 4 mm Hg preoperatively to 11 mm Hg postoperatively, and lengthening of the high pressure zone from 2.3 to 3.3 cm. One patient needed reoperation one year after fundoplication due to wrap disruption with recurrent reflux disease. Laparoscopic fundoplication involves low perioperative morbidity and shortens the postoperative recovery time in selected patients.

[Reflux disease following gastropexy for para-esophageal hiatal hernia]. / Refluxkrankheit nach Gastropexie wegen paraösophagealer Hiatushernie.

From 1984 to 1992 28 patients with paraesophageal hiatus hernia underwent elective operation with crural repair and gastropexy. In the absence of severe reflux disease (6 patients had mild to moderate reflux symptoms) and of esophagitis at endoscopy, no antireflux repair was performed in these patients. Follow-up of 19 patients after 3 years (12-72 months) revealed reflux symptoms in 11 patients (58%) and moderate or severe reflux disease (need for medical treatment) in 6 (32%). 6 patients developed new reflux symptoms after operation. 3 patients had esophagitis at endoscopy. In elective cases, the repair of paraesophageal hernia should, regardless of the presence of reflux esophagitis, be combined with an antireflux procedure to avoid the high risk of postoperative reflux disease.

[Abdominal cicatricial hernia--results of various surgical techniques]. / Abdominale Narbenhernie--Resultate verschiedener Operationstechniken.

Incisional hernias and recurrent hernias are frequent after abdominal operations. We studied possible reasons for the occurrence of recurrent hernia. From 1986 to 1990, 150 patients were operated for recurrent hernia in the St. Claraspital Basel. After a mean follow up of 5 years, 125 patients (83.3%) were evaluated. The recurrence rate of hernias--mostly first recurrences--was 19.2%; two thirds occurred in the first 24 months after operation. The time between the primary repair of the incisional hernia and the first recurrence was 23.1 months, between first and second recurrence 15.8 months and between second and third recurrence 12 months. Patients operated by a consultant showed a lower recurrence rate (16.6%) than patients operated by residents (30.4%). In primary hernias, repaired by a simple direct closure, a recurrence rate of 23.2% was observed and after a second or third operation even one of 50%. After implantation of a non-resorbable mesh, this rate was 12.5% of 14.3%, respectively. The recurrence rate was independent of the size of the defect. As result of our investigation, we would recommend to repair recurrent hernias by inserting a non-resorbable mesh by experienced operators.

[Laparoscopic and open cholecystectomy in 954 patients. A prospective evaluation]. / Laparoskopische und offene Cholezystektomie bei 954 Patienten. Eine prospektive Evaluation.

In 2 1/2 years we performed at the St. Clara Hospital in Basel 954 cholecystectomies; 661 were done laparoscopically. In the laparoscopic group we observed a morbidity of 2.3%, a reoperation rate of 0.6% and a mortality of 0.15%. In the group with open cholecystectomy the morbidity was 9.9% and the mortality 1.3%. In all 954 patients who had a cholecystectomy the morbidity was 4.6%, reoperation rate 0.4% and mortality 0.5%. Because of negative patient selection a comparison with the open cholecystectomy in our series is not possible. In summary we can say that the laparoscopic procedure has a low morbidity and low mortality. With the lesser operative trauma it allows a shorter hospital stay. We believe that laparoscopic cholecystectomy with good indication will replace open cholecystectomy as the gold standard therapy of symptomatic gallstone disease.

[Cholecystectomy today. A prospective study]. / Die Cholezystektomie heute. Eine prospektive Analyse.

Between 13 June 1990 and 12 June 1993, we performed 1145 consecutive cholecystectomies. 127 patients who had undergone additional surgery were excluded from the prospective study. Of the remaining 1018 patients, 806 (78.2%) underwent laparoscopic cholecystectomy. The conversion rate to open procedure was 11.2% (90/806). The operative morbidity associated with laparoscopic cholecystectomy was 2.1% (17/806) and with open surgery 1.9% (4/212); mortality was 0.12% (1/806) and 0.47% (1/212) respectively. The reoperation rate after laparoscopic cholecystectomy was 0.6% (5/806). Reoperation was performed for lesions of the common bile duct, bleeding, and abscess formation. If the indications for open cholecystectomy are respected the morbidity and mortality were low for both laparoscopic and conventional cholecystectomy.

[Boerhaave syndrome. Differential diagnosis in acute chest pain]. / Das Boerhaave-Syndrom. Zur Differentialdiagnose bei akuten Thoraxschmerzen.

Spontaneous perforation of the esophagus (Boerhaave syndrome) is a rare diagnosis in acute thoracic or epigastric pain. We present the case of a swiftly diagnosed and successfully treated rupture. Apart from pathophysiology, symptoms and diagnosis, the differential diagnosis and therapeutic options are discussed in more detail.

[Perioperative morbidity and mortality in colon resection for colon cancer]. / Perioperative Morbidität und Letalität der Kolonresektion bei Kolonkarzinom.

The operative risk of colon resections was evaluated by a retrospective analysis of 231 according patients who were operated on between 1984 and 1988. Mean age of the patients was 70 years with a range from 37 to 91 years. Colonic resection consisted of ileocecal resection in 3 cases, right hemicolectomy in 144 cases, segmental resection of transverse colon in 10 cases, left hemicolectomy in 22 cases, resection of sigmoid colon in 77 cases and 5 times a subtotal colectomy was performed. In two patients (0.9%) an anastomotic leak occurred. Three patients were reoperated on: one due to an anastomotic disruption, two others due to a mechanical small bowel obstruction. Two patients (0.9%) died due to systemic complications without any evidence of anastomotic or wound problems. Thus a low morbidity and mortality of colonic resection is documented in our study. Factors contributing to these results are a standardized bowel preparation, perioperative antibiotics and modern anaesthetic techniques.

[Cancer of the gastric stump. An independent disease picture? Consequences for follow-up]. / Das Magenstumpfkarzinom. Ein eigenständiges Krankheitsbild? Folgerungen für die Nachkontrolle.

In a retrospective study we analysed the clinical course of 13 patients from the St Clara's Hospital who had a gastric-stump cancer between the years of 1975 and 1989 and compared our figures with the literature. Our figures showed the average age of the patient at their first operation for the gastric ulcer was 35 and, at the second operation for gastric cancer the average age was 68.8 patients were male and 5 were female. When the tumour was discovered it was already advanced. 11 patients had a Grade 3 or 4 tumour. Out of our 13 patients, 7 had to undergo a total removal of the gastric remnant. 1 patient underwent a partial gastrectomy and, 3 patients had a gastrostomy or jejunostomy performed. For 2 patients the tumour was seen to be so advanced that no palliative procedure could be undertaken. When this study was undertaken only 1 patient remained alive and this patient had survived 7 years after removal of the gastric remnant. Because the likelihood of cancer occurring in the gastric stump is four times more frequent than expected we recommend that the patient is endoscoped 20 years after the initial operation and then again regularly every 3 to 5 years after this.

[Hemorrhage from pseudocysts caused by pseudoaneurysms in chronic pancreatitis. Diagnosis and management]. / Blutung aus pseudozysten infolge pseudoaneurysma bei chronischer Pankreatitis. Diagnostik und Management.

Bleeding pseudocysts respectively pseudoaneurysms represents a seldom complication of chronic pancreatitis in owing to erosion of pancreatic or peripancreatic arteries. The potential rupture into neighbouring organs or in the peritoneal cavity is accompanied with paramount life-threatening risks. During the last years we observed 3 patients with acute intestinal bleeding caused by pseudocysts converted to pseudoaneurysms. The goal of our report is to analyze the diagnostic tools and the management of patients with bleeding pancreatic pseudocysts, also well establish the clinical constellation, which is typical for this complication, the best diagnostic tool and the modalities to immediate control of the acute bleeding situation. All three patients suffered from chronic pancreatitis and alcohol abuse. The first patient had a known pancreatic pseudocyst, which penetrated through the gastric wall and caused a life-threatening bleeding. The second patient was admitted in owing to melena. The examinations yielded a pancreatic pseudocyst with hematosuccus pancreatis. The third patient suffered from abdominal pain and vertigo caused by anemia. With endoscopy, Cat and celiacography a pancreatic pseudocyst with cysto-colic fistula has been identified. The color-doppler ultrasound revealed a pseudoaneurysm supplied from a splenic artery branch. With management of these patients with hemorrhagic complications of pancreatic pseudocysts we acquired the following findings: 1. Patients with known chronic pancreatitis and abdominal tumor, especially when accompanied by epigastric pain and anemia, are highly suspicious for pancreatic pseudoaneurysms. 2. The color-doppler ultrasound is the best diagnostic tool, since this investigation can establish the pseudoaneurysm and identify the source.

How accurate is endorectal ultrasound in the preoperative staging of rectal cancer?

In rectal cancer, depth of infiltration and metastatic involvement of lymph nodes are important prognostic factors. The correct choice of operative treatment depends on the extent of the disease. In a prospective study, the value of endorectal ultrasound in staging rectal cancer was evaluated, and factors affecting the method's accuracy are discussed. The overall accuracy in staging depth of infiltration was 89 percent. Overstaging occurred in 10.2 percent, understaging in 0.8 percent. Tumors of the lower rectum are incorrectly staged in 16.7 percent, whereas tumors of the middle and upper rectum had an incorrect staging in 6.3 percent (P < 0.001). Compared with computed tomography, endorectal sonography is the more accurate staging method (74.7 vs. 90.8 percent). In staging lymph nodes, the overall accuracy was 80.2 percent, sensitivity was 89.4 percent, specificity was 73.4 percent, positive predictive value (PPV) was 71.2 percent, and negative predictive value (NPV) was 90.4 percent. The staging accuracy depends on the size of the node. Endorectal ultrasound is a safe, inexpensive, and accurate staging method, in the assessment of both depth of infiltration and nodal status. The results are strongly related to the experience of the investigator.