Liver transplantation is a standardized therapy for end-stage liver disease. With current immunosuppressive protocols and patient care, ten-year patient survival rate has reached 60%. Several medical complications may develop during this period, including renal dysfunction, hypertension, diabetes mellitus, hyperlipidemia, and metabolic bone disease. The aim of this article is to analyze long-term results of several clinical trials reporting common medical dysfunctions after liver transplantation and to discuss their management.
PURPOSE:To review, retrospectively, the possible causes of sub- or intertrochanteric fractures after screw fixation of intracapsular fractures of the proximal femur.METHODS:Eighty-four patients with an intracapsular fracture of proximal femur were operated between 1995 and 1998 by using three cannulated 6.25 mm screws. The screws were inserted in a triangular configuration, one screw in the upper part of the femoral neck and two screws in the inferior part. Between 1999 and 2001, we use two screws proximally and one screw distally.RESULTS:In the first series, two patients died within one week after operation. Sixty-four fractures healed without problems. Four patients developed an atrophic non-union; avascular necrosis of the femoral head was found in 11 patients. Three patients (3.6%) suffered a sub- and/or intertrochanteric fracture after a mean postoperative time of 30 days, in one case without obvious trauma. In all three cases surgical revision was necessary. Between 1999 and 2001 we did not observe any fracture after screwing.CONCLUSION:Two screws in the inferior part of the femoral neck create a stress riser in the subtrochanteric region, potentially inducing a fracture in the weakened bone. For internal fixation for proximal intracapsular femoral fracture only one screw must be inserted in the inferior part of neck.
Total colonic aganglionosis (TCA) extended to the ileum is seen quite rare among infants with Hirschsprung's disease. Type and timing of definitive surgery in these patients are controversial. This report was presented to discuss the management of two siblings with TCA. Case 1: A two-day-old girl was operated for partial intestinal obstruction. During laparotomy, serial frozen biopsies proved TCA extended to the terminal ileum and a loop ileostomy was performed. At five months of age, a modified Duhamel-Martin procedure without protective ileostomy was performed. An endo-GIA stapler was transanally used for colo-ileal anastomosis. She is doing well for the last five years. Case 2: A one-day-old boy admitted to the hospital with similar findings to his sister. Frozen biopsies during first laparotomy proved that majority of ileum and entire colon was aganglionic and a proximal ileostomy was performed. At 10 months of age, he underwent a similar Duhamel-Martin operation. He is in a good condition for the last four years. Conclusion: In infants, our modification on Duhamel-Martin procedure, which is based on the use of an endo-GIA stapler transanally for colo-ileal anastomosis without protective ileostomy, may be utilized as an alternative method in the definitive treatment of patients with TCA.
We report a 5-year-old patient with phytobezoar mimicking acute appendicitis preoperatively. During laparotomy, it was detected that terminal ileum was obstructed by several fragments of rubbery material. Bezoar was milked into the large bowel, and phytobezoar including tangerine residues was evacuated via appendix stump because of severe distended cecum, and high risk of the anastomotic leakage and intraperitoneal contamination following enterotomy of the inflamated and ischemic ileum. Postoperative course was uneventful. To date, such a procedure has not been described. We suggest that milking of vegetable fibers into the cecum and then emptying via appendix stump may be an alternative treatment of phytobezoar localizing in terminal ileum.
The placement of an intestinal stoma is still a common procedure despite the recent advantages in intestinal surgery. It is mandatory to apply meticulously sound surgical principles in order to achieve good results. Nevertheless, intestinal stomas are envisioned with a high perioperative morbidity which is mostly caused by surgical inadequacy. This can lead to considerable problems in management of the stoma in the long term and ultimately will affect quality of life of the patient. The cumulative morbidity can be given by 50% with prolaps, hernia, stenosis and necrosis as well as stoma retraction being the most relevant. In contrast, an adequate intestinal stoma will positively affect the quality of life of the patient. The availability of devices developed by the industry and the inauguration of a professional service in certain hospitals simplified the management of patients with a stoma. This significantly improved the standards of care especially regarding preoperative preparation and postoperative management. Thus, most patients are able to maintain an active and socially integrated life with minimal physical and psychical limitations.
Since 1983, lung transplantation has enjoyed increasing success and has become the mainstay of therapy for most end-stage lung diseases. While the first decade of clinical lung transplantation focused on technical details of the transplant procedure, the second decade was characterized by improvements in techniques of lung preservation and in the postoperative management. This review will focus on the recent improvements made in lung preservation and postoperative management.
The standard of care for patients with end-stage renal disease is kidney transplantation, which not only confers a survival benefit compared to hemodialysis, but is also cost-effective. The indications, contraindications as well as the preoperative assessment of recipients are discussed. The recurrence rate of the underlying renal disease has to be taken into account, especially in living donation. Growing organ shortage has lead transplant surgeons to accept older, less healthy, and even non-heart-beating donors, with generally good results. Living-donation is safe for the donor, outcome is excellent and plays an increasing role today. It has surpassed the number of cadaveric kidney transplantations in some countries. Many centres now apply laparoscopic donor nephrectomy with low morbidity. Matching for ABO blood group and HLA is routinely performed, as well as pre-transplant crossmatching. The surgical procedure has been standardized and the complication rate is low. Immunosuppressive protocols have evolved over time, and while the optimal regimen has not been defined, the availability of numerous agents allows the regimen to be individualized. New agents are being introduced into clinical practice. With increasing long-term graft survival and thus life-long immunosuppression, cardiovascular disease, de-novo malignancies and infectious complications are major causes of morbidity and mortality of transplant recipients. Effective prophylactic measures are often available, and surveillance protocols are warranted in these patients. Overall, the outcome of renal transplantation is excellent and has improved over time. Future prospects include induction of allograft tolerance, tissue engineering and xenotransplantation.
Die Inzidenz des oesophagogastralen Übergangskarzinoms nimmt gerade bei jungen weissen Männern zu (+35% in 30 Jahren). Gründe hierfür sind neben der ursächlichen Gastro-oesophagealen-Reflux-Krankheit (GERD) bisher noch nicht eindeutig bekannt. Wichtig für die Therapie ist eine korrekte Klassifizierung in die drei Subtypen: ein distales oesophageales, ein Cardia- und ein subcardiales Karzinom (Typ I, II und III). Als wichtigster Risikofaktor für die Entstehung eines Typ-I-Karzinoms gilt die "Barrett-Metaplasie" aufgrund einer langjährigen Refluxkrankheit. Bei Typ-II- und Typ-III-Karzinomen scheinen Adipositas und hoher Fettkonsum als Risikofaktoren in Betracht zu kommen. Die Beteiligung von Helicobacter pylori ist zum jetzigen Zeitpunkt noch unklar. Das präoperative Staging ist schwierig und das Tumorstadium oft (schon bei der High-grade-Dysplasie) wesentlich unterschätzt. Die Therapie dieser Karzinome besteht in der chirurgischen Resektion, wobei für Typ-I-Karzinome eine transhiatale (selten transthorakale) Oesophagektomie einschliesslich Lymphadenektomie und proximaler Magenresektion erfolgt. Typ-II- und Typ-III-Karzinome werden wie ein Magen-Karzinom mit einer totalen Gastrektomie inkl. Lymphadenektomie und distaler Oesophagusresektion versorgt. Prognostisch ungünstig sind fortgeschrittenen Tumorstadien sowie das Vorhandensein von Lymphknotenmetastasen. Ist eine R0-Resektion inkl. ausgedehnter Lymphadenektomie möglich, verbessert diese die Prognose des Patienten deutlich. Der Nutzen einer (neo-)adjuvanten Radio-Chemotherapie ist bisher noch nicht klar belegt, aussagekräftige Studien fehlen noch. Sind Fernmetastasen vorhanden, so ist eine Radio-Chemotherapie im Rahmen einer palliativen Therapie, kombiniert mit palliativen gastroenterologischen Massnahmen (Stent, PEG etc.), die Therapie der Wahl.
Thrombophlebitis is a common condition which can lead to deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE). Thrombophlebitis can reach the deep venous system via the long or short saphenous vein or via perforating veins. Between the 1 st of January 1999 and the 31 st of December 2000 a total of 17 cases of superficial (or ascending) thrombophlebitis closer than 5 cm to the deep venous system were surgically treated in our clinic. 14 times the long saphenous vein was affected and 3 times the short saphenous vein. The age of the nine females and seven males ranged from 31 to 77 (mean of 54.6) years. Duplex ultrasound was performed in all patients. In the case of a deep venous thrombosis (four cases) a computer tomography scan (CT) of the pelvis and abdomen was performed to define the extension of DVT. In all 17 (100%) cases a high ligation (crossectomy) and in four (23.5%) cases a venous thrombectomy was performed. In all of these four cases the DVT was limited to the common femoral vein. In all seventeen procedures including venous thrombectomy there was no mortality and no relevant morbidity. Mean hospitalization time was 3.1 days for crossectomy with thrombectomy, and 1.8 days for crossectomy alone. Follow-up has been so far uneventful (mean follow-up time being 12 months in the case of a DVT). In the literature there is no clear concept of how to treat, conservatively or operatively, ascending thrombophlebitis. The surgical procedure can be performed under local anesthesia, and it is safe and efficient.
Islet of Langerhans transplantation is gaining recognition as a therapy for type 1 diabetes. The procedure involves enzymatic digestion of the pancreatic tissue, purification of the islets from the exocrine tissue, infusion of the islets into the portal vein and implantation in the liver. Until 1999, and overall rate of insulin independence of 14% at one year was reported in the International Islet Transplant Registry. The results of the "Edmonton protocol" since 2000 were a breakthrough in the field, with reports of 80% insulin independence at 1-year after solitary islet transplantation in non uremic patients with brittle type 1 diabetes. A rapamycin-based, steroid-free, islet-sparing immunosuppressive regimen was designed and the problem of the insufficient islet mass was tackled by sequential infusions of islets isolated from at least two pancreatic. The University of Geneva has been involved in clinical islet transplantation since 1992, and has performed 51 allogeneic and 17 autologous. Twenty-one patients have been transplanted in Geneva since 2002. They were five solitary islet transplants, 14 islet after kidney transplants and two simultaneous islet-kidney (SIK) recipients. Insulin independence was achieved in 67%.
BACKGROUND There is accumulating evidence, both quantitative and qualitative, that pelvic irradiation affects anorectal function. However, the molecular mechanisms responsible for radiation-induced damage to the anal sphincter remain unclear. AIM To determine the expression of transforming growth factor-beta 1 (TGF-beta 1) and its downstream effector connective tissue growth factor (CTGF) in the anal sphincter of a patient irradiated for prostate cancer. PATIENT A 82 year-old patient developed a rectal adenocarcinoma and underwent an abdomino-perineal resection (APR), four years after receiving pelvic irradiation for prostate carcinoma. METHODS Tissue sections of the anal sphincter were processed for histology. Immunostaining for TGF-beta 1 and CTGF were performed. RESULTS CTGF and TGF-beta 1 immunoreactivity was detected in the irradiated anal sphincter, and was absent in controls. Immunoreactivity for both cytokines predominated in the internal sphincter. CTGF and TGF-beta 1 were preferentially detected in endothelial cells, myofibroblasts and fibroblasts; in addition, there was strong immunoreactivity for TGF-beta 1, but not for CTGF in smooth muscle cells of the anal canal. CONCLUSION Four years after pelvic irradiation, radiation-induced damage appeared to affect predominantly the smooth muscle layer of the anal canal. The molecular mechanisms responsible for radiation-induced fibrosis to these tissues involve prolonged activation of TGF-beta 1 and its downstream effector CTGF.
INTRODUCTION:Double transplantation is one possible answer to the shortage of donor organs. While each donor kidney would be unsuitable when considered as a single allograft, use of both kidneys should provide sufficient nephron mass for effective glomerular filtration.CASE REPORT:This is the first Swiss report of a dual adult transplant of marginal kidneys in a 46-year-old man, who was transplanted for the fourth time. Follow-up at 6 months is excellent without acute rejection.CONCLUSION:Recent analysis of dual marginal versus single ideal transplant outcomes, found a comparable 1-yr graft survival in both of the procedures. Long term results are still lacking and guidelines to decide between single, double or no transplantation are emerging.
Der akute Schub einer chronisch entzündlichen Darmerkrankung wird primär medikamentös behandelt. Dabei kommen in der Regel Cortisonpräparate, bei leichteren Schüben auch 5-Aminosalizylate zum Einsatz. Der anti-TNF alpha-Antikörper Infliximab kann bei therapierefraktären Crohn-Patienten verwendet werden. Die Rezidivrate ist nach medikamentöser und chirurgischer Therapie sehr hoch. Aus diesem Grunde sollte bei Patienten mit häufigen Schüben oder aggressivem Verlauf frühzeitig eine remissionserhaltende Therapie mit Immunsuppressiva (Azathioprin, 6-Mercaptopurin, Methotrexat) eingeleitet werden. Bei Patienten mit Colitis ulcerosa sollte die Remissionserhaltung primär durch 5-Aminosalizylate erfolgen. Zur Therapie der Fisteln beim M.Crohn stehen neben der Chirurgie Immunsuppressiva, Antibiotika und Infliximab zur Verfügung.
Mesothelioma are primary malignant neoplasms of the serous membranes. They usually involve the pleura and rarely the pericardium, the peritoneum and the tunica vaginalis testis. About 90% are associated with exposure to asbestos. The exposure is generally occupational, an environmental inhalation of asbestos and asbestiform fibers in areas in Turkey has been observed and presents a major health problem. This report of a patient from Anatolia with peritoneal mesothelioma after environmental exposure outlines the importance of considering this pathology in the differential diagnosis of a Turkish patient presenting with ascites.
The treatment of metastatic spinal cord compression is complex. The three treatment modalities that are currently applied (in a histologically non-specific manner) are surgery, radiotherapy and the administration of steroids. The development of new spinal instrumentations and surgical approaches considerably changed the extent of therapeutic options in this field. These new surgical techniques have made it possible to resect these tumours totally, with subsequent vertebral reconstruction and spinal stabilization. In this respect, it is important to clearly identify those patients who can benefit from such an extensive surgery. We present our management algorithm to help select patients for surgery and at the same time identifying those for whom primary non-surgical therapy would be indicated. The retrospective review of surgically treated patients in our department in the last four years reveals a meagre application of conventional guidelines for the selection of the appropriate operative approach in the surgical management of these patients. The reasons for this discrepancy are discussed.
Im Hinblick auf die postoperative Morbidität gilt die Pankreasanastomose als bedeutendster Arbeitsschritt bei der Durchführung einer Pankreasresektion. Die Gang-zu-Mukosa Pankreatiko-Jejunostomie, in der End-zu-Seit Form stellt die von uns bevorzugte und die in der Literatur am häufigsten beschriebene Technik dar. Die Einlage eines Drainagekatheters in den D.pancreaticus ist fakultativ. Das Auftreten einer Anastomoseninsuffizienz wird von der Konsistenz des Pankreas-Parenchyms, des Durchmessers des Pankreasganges und der Durchblutungsverhältnisse beeinflusst. Wichtig ist eine standardisierte Technik, die Möglichkeit der Variation des Operationsverfahrens bei Spezialsituationen und die operative Erfahrung des Chirurgen. In sogenannten "high volume" Zentren liegt die Fistelrate heute zwischen 3 und 13% und die Letalität der Pankreaskopfresektion zwischen 0.5 und 3%.
Living donor liver transplantation is a relatively new procedure in which the right side of the liver is harvested in a healthy donor and transplanted into a recipient. After the first case in 1994, over 3000 cases have been done worldwide. This review summarizes the reasons why the procedure is needed, describes its main technical aspects, highlights the boundaries in which it can be done safely, summarizes the current experience worldwide and describes the main points of the program in our unit. We argue that living-donor transplantation is a viable alternative to a long time on the waiting list for several patients, and it can be performed safely and successfully provided that all precautions are undertaken to minimize the risks in the donor and to increase the chances of a good outcome in the recipients. If these prerequisites are met, and within the framework of a structured multidisciplinary program, we believe that living-donor liver transplantation should be funded by health insurances as a recognized therapeutic option.
Über die Frage der besten oder "richtigen" Technik bei gastrointestinalen Anastomosen wird seit je diskutiert. Die Ansprüche an eine gute Anastomosentechnik sind: Gute Durchblutung, Wasserdichtigkeit, Spannungsfreiheit, Sicherheit, leichte Durchführbarkeit, wenig Unruhe und Verschmutzung im Operationsgebiet und geringe Kosten. Die Operationstechnik der extramukösen, fortlaufenden Anastomosentechnik im Gastrointestinaltrakt wird in Wort und Bild erläutert. Anhand einer Pilotstudie, einer randomisierten Vergleichsstudie, einer Schweizer Multizenterstudie und schliesslich einer 5-jährigen Qualitätskontrollstudie wird gezeigt, dass diese "Schweizer"-Technik allen Anforderungen zur Durchführung einer "idealen" Anastomose gerecht wird und an fast allen intestinalen Lokalisationen verwendet werden kann.
