[Laparoscopic fundoplication for gastroesophageal reflux disease (GERD)]. / Laparoskopische Therapie der Refluxkrankheit.

Laparoscopic fundoplication became the gold standard in the surgical therapy of GERD. In comparison with open procedures, laparoscopic antireflux surgery has a lower morbidity rate, a better early and late postoperative outcome and is more cost-effective. Antireflux surgery can be performed after a critical evalutation of the patient including gastroscopy, biopsy, 24h-pH-manometry and after a long lasting conservative medical treatment. Indications for antireflux surgery are given by a failed medical treatment, an insufficient compliance, complications of GERD, i.e. stenosis, Barrett-esophagus and atypical reflux symptoms like chronic cough, hoarseness or thoracic pain with presence of a pathological pH-monitoring. Laparoscopic 360 degrees Nissen-fundoplication with crurorrhaphy is our standard procedure, whereas the 270 degrees Toupet technique in our tailored approach is the technique of choice for esophageal motility disorders. Results of antireflux surgery published in literature are discussed and compared with our own ten years experience with 124 cases of laparoscopic fundoplication.

Selective enhancement of gene transfer by steroid-mediated gene delivery.

The incorporation of transgenes into the host cells' nuclei is problematic using conventional nonviral gene delivery technologies. Here we describe a strategy called steroid-mediated gene delivery (SMGD), which uses steroid receptors as shuttles to facilitate the uptake of transfected DNA into the nucleus. We use glucocorticoid receptors (GRs) as a model system with which to test the principle of SMGD. To this end, we synthesized and tested several bifunctional steroid derivatives, finally focusing on a compound named DR9NP, consisting of a dexamethasone backbone linked to a psoralen moiety using a nine-atom chemical spacer. DR9NP binds to the GR in either its free or DNA-crosslinked form, inducing the translocation of the GR to the nucleus. The expression of transfected DR9NP-decorated reporter plasmids is enhanced in dividing cells: expression of steroid-decorated reporter plasmids depends on the presence of the GR, is independent of the transactivation potential of the GR, and correlates with enhanced nuclear accumulation of the transgene in GR-positive cells. The SMGD effect is also observed in cells naturally expressing GRs and is significantly increased in nondividing cell cultures. We propose that SMGD could be used as a platform for selective targeting of transgenes in nonviral somatic gene transfer.

[Laparoscopic fundoplication for gastroesophageal reflux: experience with 49 surgical patients (1994-1999)]. / Laparoskopische Antirefluxchirurgie beim gastroösophagealen Reflux: Erfahrungen mit 49 operierten Patienten (1994-1999).

INTRODUCTION: Chronic gastrooesophageal reflux disease (GERD) is the most common benign pathology of the upper gastrointestinal tract in the western world. We report our experience of laparoscopic antireflux surgery. PATIENTS AND METHODS: 49 patients underwent laparoscopic antireflux surgery at our clinic between 1994 and 1999. 48 patients were followed up in a retrospective study. Mean follow-up was 30 months (2-66). 31 patients (64.6%) were male and 17 female (35.4%). Mean age was 48 years (26-74). The surgical method was tailored to the case: total Nissen fundoplication (87.5%) was indicated after ruling out oesophageal motility disorders by manometry. In 6 patients (12.5%) with coexisting dysphagia or pathological manometry, partial posterior fundoplication (Toupet) was performed. RESULTS: Mean operating time of 215 minutes (125-420) for the first 10 Nissens was significantly reduced to 119 minutes (70-190) for the last 10 procedures with increasing experience of the surgeon. No severe intraoperative complications occurred and mortality was 0%. Conversion rate was 4.2%. Mean hospital stay was 6.1 days (1-36). At follow-up 93.7% were free of reflux symptoms without medication, and only one patient (2.1%) suffered from regular reflux which had to be treated with PPI daily. 2 patients (4.2%) took PPI only occasionally. Persistent dysphagia occurred in 7 patients (14.8%). 5 (10.5%) underwent one or more endoscopic dilatations, after which 3 patients (6.3%) reported an improvement of dysphagia. No patient needed reoperation on due to mechanical complications. 1 patient (2.1%) developed a paraoesophageal hernia 4.5 years after a Nissen procedure. According to the Visick Score, 95.8% of all patients were satisfied with their outcome (Visick I/II). CONCLUSIONS: With careful investigation and indication, laparoscopic antireflux surgery is a safe and effective alternative method to long-term medication with PPI in the treatment of gastrooesophageal reflux disease. Morbidity is low. Persistent postoperative dysphagia can be reduced with either a short and floppy total fundoplication or a partial wrap.

[Extraovarian peritoneal serous papillary carcinoma: an unusual surgical case]. / Das extraovarielle sero-papilläre Karzinom des Peritoneums--Eine chirurgische Rarität.

The extraovarian peritoneal serous papillary carcinoma (EPSPC) is a multicentric peritoneal tumor with minimal or absent involvement of the ovaries. The actual treatment regimen consists of a cytoreductive surgery followed by a combination chemotherapy. Few studies have compared outcome of EPSPC to papillary serous ovarian cancer (PSOC). Several authors have documented similar clinical behavior between EPSPC and PSOC, but this finding has not been universal. A 64-year-old female patient with symptomatic gall stone disease underwent elective laparoscopic cholecystectomy. Unexpectedly we found some uncommon small nodular structures on the serosa of the right colon. The histological findings suggested a poorly differentiated peritoneal serous papillary carcinoma. Biopsies of both ovaries showed no signs of tumor infiltration and the diagnosis of EPSPC was established. After surgery, a combination chemotherapeutic regimen with carboplatin and cyclophosphamid was given. Laparoscopic reassessment 7 months after the first procedure showed no tumor. 3 identical cycles completed chemotherapy. Normal ovaries and no other tumor sites were found in a final laparoscopic look after 11 months.

Incidence of port site recurrence after laparoscopic cholecystectomy for preoperatively unsuspected gallbladder carcinoma.

BACKGROUND: We sought to determine the incidence of recurrence of carcinoma at the port site and the outcome of patients with such recurrences after exploratory laparoscopy/laparoscopic cholecystectomy for unsuspected gallbladder carcinoma and analyzed aspects of the laparoscopic procedure associated with recurrences at the port site. METHODS: Thirty-seven patients with preoperatively unknown adenocarcinoma of the gallbladder were analyzed. The patients were part of a large prospective study of the Swiss Association of Laparoscopic and Thoracoscopic Surgery including 10,925 patients undergoing laparoscopic cholecystectomy. RESULTS: Preoperatively undiagnosed adenocarcinoma of the gallbladder is rarely encountered in patients undergoing laparoscopic cholecystectomy (0.34%). The incidence of recurrence of carcinoma at the port site in these patients is 14% (5 of 37) and is similar whether the primary tumor is confined to the gallbladder (T1/T2) or locally advanced (T3/T4). The recurrences at the port site were diagnosed within 6 to 16 months (median 10 months) after the operation. Patients with an intraoperative perforation of the gallbladder had a higher incidence of recurrences at the port site (40%) than had patients without perforation (9%; P = .13). All patients with recurrences at the port site had distant metastases and all died of the disease 12 to 35 months (median 19 months) after cholecystectomy; all patients with such recurrences and stage T1/T2 tumors subsequently had peritoneal metastases. CONCLUSIONS: Patients with a preoperatively undiagnosed adenocarcinoma of the gallbladder undergoing laparoscopy or laparoscopic cholecystectomy have a high incidence of recurrences at the port site, and the incidence increases when a gallbladder perforation occurs during the operation. All patients with such recurrences died of the disease. The diagnosis of an isolated recurrence at the port site may therefore be an indicator of disseminated disease in most cases.

Complications of laparoscopic cholecystectomy in Switzerland. A prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery.

BACKGROUND: We set out to analyze the technical aspects, intraoperative complications, morbidity, and mortality of laparoscopic cholecystectomy in a multi-institutional study representative of Switzerland. METHODS: Data were collected from 10,174 patients from 82 surgical services. A total of 353 different parameters per patient were included. RESULTS: We found intraoperative complications in 34.4% of patients and had a conversion rate of 8.2%. This rate was significantly increased in patients with complicated cholelithiasis and in those with previous upper-but not lower-abdominal surgery. In most cases, conversions to open procedures were required because of technical difficulties due to inflammatory changes and/or unclear anatomical findings at the time of operation. Bleeding was a common intraoperative complication, that significantly increased the risk of conversion. Patients with loss of gallstones in the peritoneal cavity had increased rates of abscesses. The rate of common bile duct injuries was 0.31%, but it decreased significantly as the laparoscopic experience of the surgeon increased. The rate of common bile duct injuries was not increased in patients with acute cholecystitis or in the 1.32% of patients undergoing laparoscopic common bile duct exploration. Intraoperative cholangiography did not reduce the risk of common bile duct injuries, but it allowed them to be diagnosed intraoperatively in 75% of patients. Local complications were recorded in 4.79% of patients, and systemic complications were seen in 5.59%. The mortality rate was 0.2%. CONCLUSIONS: Although laparoscopic cholecystectomy is a safe procedure, the rate of conversion to open cholecystectomy is still substantial. The conversion rate depends both on the indication and intraoperative complications. There is still a 10.38% morbidity associated with the procedure; however, the incidence of common bile duct injuries, which decreases with growing laparoscopic experience, was relatively low.

Spilled gallstones after laparoscopic cholecystectomy. A relevant problem? A retrospective analysis of 10,174 laparoscopic cholecystectomies.

BACKGROUND: Spilled gallstones after laparoscopic cholecystectomy may cause abscess formation, but the exact extent of this problem remains unclear. METHOD: The data (collected by the Swiss Association of Laparoscopic and Thoracoscopic Surgery) on 10,174 patients undergoing laparoscopic cholecystectomy at 82 surgical institutions in Switzerland between January 1992 and April 1995 were retrospectively analyzed with special interest in spilled gallstones and their complications. RESULTS: In 581 cases (5.7%) spillage of gallstones occurred; 34 of these cases were primarily converted to an open procedure for stone retrieval. Of the remaining 547 cases only eight patients (0.08%) developed postoperatively abscess formation requiring reoperation. CONCLUSIONS: Spillage of gallstones after laparoscopic cholecystectomy is fairly common and occurs in about 6% of patients. However, abscess formation with subsequent surgical therapy remains a minor problem. Removal of spilled gallstones is therefore not recommended for all patients, but an attempt at removal should be performed whenever possible.

[Laparoscopic colon surgery in the regional hospital: initial experiences after 65 interventions]. / Laparoskopische Kolonchirurgie im Regionalspital: erste Erfahrungen nach 65 Eingriffen.

321 colorectal operations have been performed in our institution in a 4-year period from 1992 to 1996. They included 65 laparoscopic interventions for benign disease or for palliative treatment of malignancy. 40 patients underwent low anterior resections, mostly for diverticular disease. 11 right hemicolectomies, 3 left hemicolectomies, 1 total colectomy and 7 rectopexies (6 with sigmoid resection) were performed. 3 patients with advanced malignant disease underwent colostomy. There was a conversion rate of 26%, largely due to adhesions or unclear anatomy, decreasing with increasing experience. One trokar-injury of a major vessel required immediate conversion to laparotomy. 2 reoperations were performed, for an anastomotic leakage after low anterior resection and an incarcerated port-site-hernia respectively. A rather high rate of wound infections (27%) was reduced to 15% by modifying the technique for retrieval of the specimen. The median postoperative hospital stay was 11.6 days. The trend towards shorter hospital stay and recovery should not result in uncritical use of laparoscopy in colon surgery, in an attempt to meet the rising demand for less postoperative pain and shorter hospital stay. This criticism mainly applies to tumor surgery, where laparoscopic procedures are indicated in our institution only for palliative treatment.

[Etiology, pathogenesis and classification of anal fissure]. / Atiologie, Pathogenese und Klassifikation der Analfissur.

Anal fissure is one of the most common causes of anal pain but its etiology and pathophysiology remain obscure. Many theories have been advanced to explain the origin of anal fissures but trauma of faecal mass and hypertonicity of the internal sphincter seem to be the most important factors. The initial lesion in anal fissure is a tear in the anoderm mostly in its posterior midline caused by overstretching of the anal canal. Secondary fissures may occur on a commonly lateral position as a result of inflammatory bowel disease, previous anal surgery, venereal, dermatologic, infectious or neoplastic disease. As the fissure becomes deeper and more chronic the sclerotic fibres of the internal anal sphincter are seen as well as a sentinel pile and a hypertrophied anal papilla. The disease enters in a vicious circle of anal pain, constipation, faecal trauma and sphincter spasm.

[The clinic as profit center and management with reference figures]. / Die Klinik als Profit-Zentrum und Führung mit Kennzahlen.

Financial responsibility is one of the important aspects of hospital management. At the hospital of Uster a trial with a profit center concept was started in October 1991. This concept included development of management tools such as reference figures to check costs, returns and performance. Thus it was possible to obtain an equilibrium between personnel costs and performance within 6 months. In the first half of 1993 the budgeted performance figures for 1993 have so far been reached. Although a complete implementation of a profit center concept in a public hospital does not seem possible, a profit center-like structure helps to obtain financial control and enables the hospital management to readily adapt to changing conditions.

A nation's experience in laparoscopic cholecystectomy. Prospective multicenter analysis of 3722 cases.

In a national prospective multicenter study 3,722 laparoscopic cholecystectomies (LC) performed by 179 surgeons in 50 institutions were analyzed with special regard to technique and complications. Conversion to open cholecystectomy was necessary in 259 patients (7.0%), either without intraoperative complications (4.5%) or due to intraoperative complications (2.5%). Three patients (0.08%) died within 30 days after operation and a total of 39 patients (1.0%) had to be reoperated; 22 (0.6%) bile duct injuries were registered. Common bile duct (CBD) stones were treated mainly by ERCP. In eight cases laparoscopic removal of common bile duct stones was attempted, and it was performed successfully in six patients. Postoperatively patients were discharged home after a mean of 4.4 days and returned to work after 14.0 days (range: 2-28). Laparoscopic cholecystectomy became the golden standard to remove the gallbladder, but further development is needed to establish laparoscopic treatment of biliary tract stones in the near future.

[Laparoscopic appendectomy: techniques and results in Switzerland]. / Die laparoskopische Appendektomie: Techniken und Resultate in der Schweiz.

We have tried to assess the actual attitude towards laparoscopic appendectomy in Switzerland. An inquiry on preoperative investigations, operative approach and results in cases of suspected appendicitis in 26 surgical Institutions affiliated to the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) was performed. In a 20 month period a total of 3665 laparoscopic procedures were performed. Appendectomy was attempted in 457 cases in 19 institutions. Conversion to open appendectomy was necessary in 51 cases (11%). Average operative time was 62 minutes. There were 27 postoperative complications (7%). 8 patients (1.9%) needed reoperation. Mean hospital stay was 3.9 days. Opinions of the participating institutions on the actual role of laparoscopic appendectomy (feasibility, advantages or disadvantages) are shown.

[Significance of laparoscopic surgery in the treatment of cholecysto- and choledocholithiasis]. / Die Bedeutung der laparoskopischen Chirurgie in der Behandlung der Cholezysto- und Choledocholithiasis.

The management of common bile duct stones during laparoscopic cholecystectomy contains some controversy. Our first aim is to detect choledocholithiasis preoperatively making use of a preoperative ultrasound and cholangiogram routinely. Laparoscopic cholecystectomy will follow a preoperative ERCP with endoscopic sphincterotomy and stone extraction in this desirable situation. Cystic duct cholangiography which should become a routine procedure during laparoscopic surgery is feasible in 90-99% and will detect unsuspected common duct stones and iatrogenic bile duct injuries with an accuracy rate of 75.4-90%. This investigation can replace the preoperative cholangiogram in future. A intraoperatively detected common bile duct stone can be managed nowadays by ERCP and sphincterotomy postoperatively or by converting the laparoscopic cholecystectomy into an open common bile duct exploration. Laparoscopic common bile duct exploration is of increasing demand but not yet a routine procedure. If choledocholithiasis will be diagnosed postoperatively, a ERCP with papillotomy will be performed as well. An inquiry among 50 members of the Swiss society of laparoscopic and thoracoscopic surgery (ALTC) with 3718 laparoscopic cholecystectomies pointed out their opinion about the management of common bile duct exploration during laparoscopic surgery in the presented paper.

Upper gastrointestinal hemorrhage preceding development of Bouveret's syndrome.

Gastric outlet obstruction by a gallstone is a very uncommon clinical entity; it was first reported by Bouveret in 1896. In the patient presented, we were able to show the development of formation of the bilioenteric fistula with massive arterial bleeding from the eroded cystic artery until duodenal occlusion. The process was endoscopically and radiologically observed and documented. Although the diagnosis was made immediately, the patient had to undergo surgery because the gallstone proved to be too large to be extracted endoscopically.

[Laparoscopic cholecystectomy in Switzerland. Critical retrospective evaluation of the first 3,722 cases. Swiss Professional Society of Laparoscopic and Thoracoscopic Surgery]. / Laparoskopische Cholecystektomie in der Schweiz. Kritischer Rückblick auf die ersten 3722 Fälle. Schweizerische Arbeitsgemeinschaft für Laparoskopische und Thorakoskopische Chirurgie.

In a national prospective multicenter study 3722 laparoscopic cholecystectomies (LC) performed by 179 surgeons in 50 Swiss institutions were analysed with special regard to technique and complications. Conversion to open cholecystectomy was necessary in 259 patients (7.0%), either expectively without intraoperative complications (4.5%) or due to intraoperative complications (2.5%). Three patients (0.08%) died within 30 days after operation and a total of 39 patients (1.0%) had to be reoperated. 31 (0.8%) bile duct injuries were registered. Common bile duct (CBD) stones were treated mainly by ERCP. In 8 cases laparoscopic removal of common bile duct stones was attempted and performed successfully in 6 patients. Postoperatively patients were discharged home after a mean of 4.4 days and returned to work after 14.0 days (range: 2-28). Laparoscopic cholecystectomy became the gold standard to remove the gallbladder, but further development is needed, to establish laparoscopic treatment of biliary tract stones in the near future.

Differential inhibition of human secretory and cytosolic phospholipase A2.

The roles and relative contributions of secretory and cytosolic phospholipases A2 in physiology and pathology are not precisely known. In a search for differential inhibitors of these enzymes, which could serve as tools to clarify this issue, we evaluated the potencies of reference compounds and three series of new compounds, viz. substrate analogues, 1,2-amino alcohols and enolized beta-tricarbonyl derivatives, as inhibitors of secretory phospholipase A2 from human polymorphonuclear leukocytes (sPLA2) and of cytosolic phospholipase A2 from human U937 cells (cPLA2). With few exceptions, the compounds selected are potent inhibitors of sPLA2 with IC50 values (concentration inhibiting 50%) in the low micromolar range. Inhibition of cPLA2 was only observed with some phosphate-free substrate analogues, with 1,2-amino alcohols and two of seven reference compounds. These results suggest that inhibition of secretory and of cytosolic phospholipases A2 are independent effects. Several inhibitors could be identified with a marked selectivity for sPLA2.

[Surgical therapy of diverticular disease at the Waid City Hospital, Zurich, 1980-1990]. / Die chirurgische Therapie der Divertikelkrankheit am Stadtspital Waid Zürich 1980-1990.

Our experience with 431 patients suffering from diverticular disease is presented. Indications for emergency (severe bleeding, bowel obstruction, sigmoid perforation with peritonitis) and elective surgery (recurrent attacks of diverticulitis or bleeding, painful or obstructing diverticular disease, fistula, impossibility to exclude a cancer) are given. Resection of the perforated sigmoid by the Hartmann procedure helps to reduce mortality markedly for diffuse purulent and fecal peritonitis. A resection with primary anastomosis can be performed with equal safety for a more localised peritonitis. Aggressive indication for elective surgery helps to lower mortality and morbidity in symptomatic diverticular disease.

[Laparoscopic cholecystectomy. Results and experiences 1 year following introduction of a new surgical technique (139 cases)]. / Die laparoskopische Cholezystektomie. Ergebnisse und Erfahrungen ein Jahr nach Einführung der neuen Operationstechnik (139 Fälle).

Laparoscopic cholecystectomy is on the way to become the procedure of choice for treatment of uncomplicated cholelithiasis. First experiences are summarized: Within the first year after introduction 139 patients, 100 women and 39 men, have been treated by this novel technique. 33 open cholecystectomies were carried out in the same period. In addition to simple cholecystolithiasis 11 patients had prior biliary pancreatitis and/or sphincterotomy because of choledocholithiasis, 16 patients had suffered before from acute cholecystitis, 3 patients were operated on with the diagnosis of acute cholecystitis and 3 patients underwent simultaneous laparoscopic intervention. Seven times the laparoscopic procedure had to be converted into an open one because of intraoperative complications, twice because of a lesion to the common bile duct, three times because of intractable bleeding, once because of obscure anatomic conditions and once because of a technical failure in establishing the pneumoperitoneum. Four postoperative complications could be treated conservatively. In the average, patients complained about pain for 2 days, stayed in the hospital 4.4 days and assumed their usual activity after 13 days. An extension of indications for laparoscopic cholecystectomy should be sought stepwise according to gained experience. The problem of technical training of surgeons persists and must be solved in priority.

[Diverticular disease: When to operate?]. / Die Divertikelkrankheit: Wann soll operiert werden?

We present our experience with 431 patients suffering from diverticular disease. Indications for emergency and elective surgery are given. Immediate laparatomy is mandatory for severe diverticular bleeding, bowel obstruction and sigmoid perforation. Aggressive surgical management is appropriated for purulent and fecal peritonitis. Resection of the perforated sigmoid colon by the Hartmann procedure is the method of choice and helps to reduce mortality markedly. A resection with primary anastomosis can be performed in equal safety if there is only a localised peritonitis. One stage resection is most frequently performed for elective cases with recurrent attacks and bleeding, painful or obstructing diverticular disease, fistula and if a cancer cannot be excluded. Aggressive surgical treatment helps to lower mortality and morbidity and is the best tool in prevention of severe complications for diverticular disease.