Ernst Bodner

Survival and local recurrence after anterior resection and abdominoperineal excision for rectal cancer

The aim of this retrospective study is to compare the outcome of abdominoperineal excision (APE) and anterior resection (AR) for rectal cancer in 136 patients. Local recurrence rates and 5-year survival probabilities were estimated for the AR and APE group. Further comparisons were carried out between hand-sewn and stapled anastomoses after AR, and between patients after AR and APE for tumours 2 to 6 cm from the dentate line. Local recurrence after AR occurred in 14% and after APE in 10% of these cases. Five-year survival probabilities and local recurrence frequencies showed no statistically significant difference (P > 0.05). Local recurrence rates were 13.5% after hand-sewn anastomoses and 15% after the stapled procedure. No statistically significant difference was observed in the 5-year survival and recurrence rate (P > 0.05). Seventy-four of 136 patients had tumours located 2 to 6 cm from the dentata line. Local recurrence occurred in 21% after AR and 5% after APE, showing a statistically significant difference in frequency (P < 0.05). No significant difference was found in cumulative 5-year survival probabilities. APE for advanced low rectal cancer showed a significant reduction in local recurrences compared to AR.

Management of Hyperparathyroidism in an Endemic Goiter Area

Abstract. In an endemic goiter area patients with hyperparathyroidism (HPTH) frequently also have thyroid abnormalities. In a retrospective study of 95 patients with HPTH we assessed the diagnostic accuracy of imaging techniques (ultrasonography or radionuclide scanning) for preoperative localization of parathyroid adenomas. Altogether 86% of our patients had goiter, requiring thyroid resections in 37%. For 19 patients the parathyroid exploration was the second or third cervical operation, most of them due to goiter. We found that the overall rate of transient and permanent recurrent nerve paralysis is considerably increased in patients with previous neck surgery (26% vs. 7%). The combination of ultrasonography and radionuclide scanning can lead surgeons to the site of parathyroid lesions responsible for HPTH in 85% of cases, although frequent nodular goiters can produce pitfalls for correct imaging in iodine-deficient countries. In endemic goiter areas preoperative localization studies can be recommended in patients with primary HPTH—for evaluation of thyroid pathology possibly leading to resection or its accuracy in localizing parathyroid adenomas. These studies also seem justified in patients with previously unsuccessful neck explorations for HPTH.

Gastroesophageal reflux disease associated with poor esophageal body motility is effectively treated by laparoscopic toupet fundoplication

SummaryBackgroundThe Nissen fundoplication, an effective treatment for gastroesophageal reflux disease (GERD), may frequently cause dysphagia in patients with poor esophageal body motility.MethodsThe laparoscopic Toupet fundoplication was performed in 24 patients with gastroesophageal reflux disease (GERD) with poor esophageal body motility of whom 18 (75%) presented with intermittent (n=16) or persistent (n=2) dysphagia for solids. Patients were followed-up for up to 12 months following surgery.ResultsPerioperative complications occurred in 4 patients (16.7%) including gastric perforation (n=1), intraabdominal hematoma (n=1), deep venous thrombosis of the calf (n=1) and pneumonia (n=1). There was no mortality and no conversion to open laparotomy among our patients 95.8% of patients were satisfied with surgery (Visick grade 1 or 2). Postoperatively 2 patients (8.4%) complained of dysphagia, one required reoperation due to too tight approximation of the hiatal crura.ConclusionsThe laparoscopic Toupet fundoplication is an effective treatment for GERD with poor esophageal body motility.ZusammenfassungGrundlagenDie Nissenfundoplikation, welche eine wirksame Therapie der gastroösophagealen Refluxkrankehit ist, führt bei Patienten mit beeinträchtigter Ösophagusperistaltk häufig zu Dysphagie.MethodikAn 24 Patienten mit gastroösophagealer Refluxkrankheit und beeinträchtigter Ösophagusperistaltik wurde die laparoskopische Toupet Fundoplikation durchgeführt. 18 (75%) dieser Patienten litten präoperativ unter intermittierender (n=16) oder permanenter (n=2) Dysphagie für feste Speisen. Die Patienten wurden im Median 6 Monate (Range: 3 bis 12 Monate) nach erfolgter Operation kontrolliert.ErgebnissePerioperative Komplikationen wie Magenperforation (n=1), intraabdominelles Hämatom (n=1), tiefe Unterschenkelvenenthrombose (n=1) und Pneumonie (n=1) traten bei 4 Patienten (16.7%) auf. Bei keinem der Patienten kam es zu einer letalen Komplikation, ebenso war in keinem Fall ein Umsteigen auf eine offene Vorgansweise notwendig. 95,7% der Patienten waren mit dem Ergebnis des Eingriffes zufrieden (Visik-Grad 1 oder 2). Postoperativ klagten 2 Patienten (8,4%) über Dysphagie, in einem Fall war eine Reoperation notwendig, da der Hiatus durch eine Naht zu stark eingeengt wurde.SchlußfolgerungenDie laparoskopische Toupet-Fundoplikation ist ein wirksames Verfahren zur Behandlung von Refluxpatienten mit beeinträchtigter Ösophagusperistaltik.

Surgical therapy for primary hyperparathyroidism in patients with previous thyroid surgery

BACKGROUND In patients with primary hyperparathyroidism (HPTH) and previous thyroid operations, complications of parathyroidectomy are more frequent than in patients undergoing initial neck surgery. The aim of this study was to investigate the value of preoperative imaging with regard to its influence on the surgical strategy. METHODS We retrospectively analyzed 17 patients with primary HPTH and previous thyroid surgery. Preoperatively 16 patients underwent sonography and/or scintigraphy. RESULTS Sonography had an overall accuracy to correctly localize enlarged parathyroid glands of 80%, and scintiscanning had overall accuracy of 78.6%. The accuracy of localization was increased up to 84.6% if both diagnostic procedures were applied. In patients with normal thyroid residues the accuracy of sonography was 85.7%, and it was 100% if scintiscanning was used. CONCLUSIONS Preoperative localization techniques in patients with primary HPTH and previous thyroid surgery have high accuracy. This allows for an imaging-directed operative strategy, thus preventing unnecessary bilateral neck explorations, which carry a high risk of recurrent laryngeal nerve injury.

Obstructive ileus of large bowel is associated with low tissue levels of neuropeptides in prestenotic bowel segment.

The neuropeptides substance P, vasoactiveintestinal polypeptide, and the recently discoveredpeptide secretoneurin are neurotransmitters of theintrinsic nervous system of the gut and effect gutmotility. The aim of this study was to investigatewhether these neuropeptides are involved in thepathophysiology of large bowel ileus. Five patientsunderwent colonic resections for obstructive cancer ofthe colon. Full-thickness specimens of the resected colonwere taken 10 cm proximal and 10 cm distal to the siteof tumor obstruction. Substance P-, vasoactiveintestinal polypeptide-, and secretoneurin-likeimmunoreactivities were measured in the specimens byradioimmunoassay. In addition immunocytochemistry wasperformed. Tissue levels of substance P, vasoactiveintestinal polypeptide, and secretoneurin were lower inthe prestenotic than in the poststenotic bowel segment. Inaccordance, immunocytochemistry revealed a denserstaining of ganglion cells and fibers for all threeneuropeptides in the poststenotic bowel. The decreasedtissue levels of substance P, vasoactive intestinalpolypeptide, and secretoneurin in the prestenotic bowelsegment may contribute to the final decompensation ofobstructive ileus.

First Experiences with Robotic‐Assisted Laparoscopic Cholecystectomies

SummaryBackground: The recent introduction of surgical robotic systems marks a new milestone in surgical medicine comparable to the laparoscopic approach in the late 1980s. At Innsbruck University Hospital we have been using the da Vinci™ robotic system (Intuitive Surgical, Mountain View, CA, USA) since June 2001. Our first general surgical experiences with this device and laparoscopic cholecystectomies are reported here. Methods: The da Vinci™ robot is a supervised on-line system in which the surgeon at a remote console controls the endoscopic instruments and a binocular 3-D videoscope via three robotic arms. A scrubbed ‘conventional’ team consisting of at least one surgeon and a nurse assists the procedure to change the robotic surgical instruments as well as to allow immediate conversion to a conventional laparoscopic or open procedure, if necessary. During the first 6 months, 25 cholecystectomies were performed using the da Vinci™ surgical robot. Results: Two out of 25 cholecystectomies had to be converted to conventional laparoscopy due to system break-down. Two intraoperative complications were managed successfully, and one redo-operation was necessary because of postoperative bleeding at a port site. Operating time was 100 (60–171) min with a duration of 52 (35–99) min for the robot-assisted act itself. Postoperative results and hospitalization times did not differ from conventional laparoscopic procedures. Conclusions: Laparoscopic cholecystectomy can be performed with the surgical robotic da Vinci™ system as safely as with the conventional laparoscopic approach. The longer operating time is mainly due to the learning curve and the time-consuming installation of the robot itself. Laparoscopic cholecystectomy is the ideal procedure for learning and teaching robot-assisted operations in general surgery. Although the present limitations of the system are evident (cumbersome equipment, lack of special instruments, only two working arms) we feel ready to perform more complex procedures in the near future.ZusammenfassungGrundlagen: Operationsroboter stellen die innovativste, technische Weiterentwicklung der laparoskopischen Chirurgie seit dem Ende der 80er Jahre dar. Die Universitätsklinik Innsbruck verfügt seit Juni 2001 über den da Vinci™ Operationsroboter (Intuitive Surgical, Mountain View, CA). Wir berichten über unsere ersten Erfahrungen mit dem Roboter an Hand von 25 Cholezystektomien. Methodik: Beim da Vinci™ Operationsroboter steuert der Chirurg von einer Konsole aus, über drei Roboterarme eine 3-D-Kamera sowie spezielle laparoskopische Instrumente. Direkt beim Patienten befinden sich ein weiterer Chirurg und eine Instrumentenschwester, die das Auswechseln der Instrumente an den Roboterarmen übernehmen und jederzeit bereit sind, den Eingriff konventionell laparoskopisch oder offen weiterzuführen. In den ersten sechs Monaten wurden 25 Cholezystektomien mit dem da Vinci™ Operationsroboter durchgeführt. Ergebnisse: Zweimal mußte aufgrund eines technischen Gebrechens am Gerät auf das konventionelle laparoskopische Verfahren umgestiegen werden. Es traten zwei beherrschbare intraoperative Komplikationen auf. Eine Revision erfolgte aufgrund einer Blutung aus einer Trokareinstichstelle. Die mediane Operationszeit betrug 100 (60–171) min, wobei der eigentliche Roboterakt 52 (35–99) min dauerte. Die postoperativen Ergebnisse sowie die stationäre Aufenthaltsdauer unterscheiden sich nicht von denen konventionell laparoskopisch operierter Patienten. Schlußfolgerungen: Die laparoskopische Cholezystektomie kann mittels Operationsroboter ohne Qualitätsverlust durchgeführt werden. Die im Vergleich zur konventionellen laparoskopischen Cholezystektomie längere Operationszeit ist in erster Linie auf die Aufrüstzeit des Roboters zurückzuführen, der Eingriff selbst dauert mit einiger Erfahrung sogar kürzer. Die roboterassistierte Cholezystektomie stellt in der Allgemeinchirurgie die ideale Lehr- und Lernoperation für das Arbeiten mit dem Operationsroboter dar. Trotz der momentan noch systembedingt begrenzten technischen Möglichkeiten (limitierte Auswahl an Arbeitsinstrumenten, Fehlen eines dritten Roboterarms für Instrumente, unpraktische Instrumente) streben wir komplexere Eingriffe mit dem Operationsroboter für die nahe Zukunft an.

Stellenwert der Laparoskopie und laparoskopischen Endosonographie beim Pankreaskarzinom

SchlußfolgerungenEs ist vielfach nicht möglich, kleine oberflächliche oder intraparenchymatöse Lebermetastasen mit konventionellen bildgebenden Verfahren zu diagnostizieren. Das möglichst exakte präoperative Staging ist allerdings entscheidend für die Indikationsstellung zur Laparotomie und radikalen Resektion sowie für die Beurteilung der Prognose. Nach unserer Erfahrung ist die präoperative Laparoskopie/LUS eine geeignete Methode, um zusätzliche Staging-Informationen bei Patienten mit Pankreaskarzinomen zu erhalten.

Adjuvant Intraoperative Radiation Therapy During Duodenopancreatectomy

Intraoperative radiation therapy (IORT) is a modern oncological treatment, utilizing radiotherapy and surgery at the same time. The idea to administer radiation to internal structures was first published by Carl Beck, a Berlin surgeon, in 1908 in a paper entitled “On external Roentgen treatment of internal structures (eventration treatment)” [1].

Transoral Tracheal Intubation for Gastroscopy in Rats

Abstract: A new method of orotracheal intubation in rats which was developed to prevent apnea during upper gastrointestinal endoscopiy is described. After the anesthetized animals are relaxed with an I. V. injection of Vecuronium, orotracheal intubation was performed with a thin endoscope under complete visual control. After relaxation is achieved the glottis is wide open and intubation can be performed carefully without any medianical irritation of the larynx. After placement of the tube in the trachea, the fiberoptic was removed and pressure–controlled ventilation occurred.

Nipple complication caused by a mesenteric GORE-TEX® sling reinforcement in a kock ileal reservoir

INTRODUCTION: The surgical trend after proctocolectomy at present is to perform a pelvic pouch reservoir with an ileoanal anastomosis. Before that a continent ileal Kock pouch was the procedure of choice, which enabled the patient to collect the intestinal discharge for several hours and avoid involuntary escape of reservoir contents, thus making the wearing of plastic bags unnecessary. Although in the majority of patients an increased life quality can be observed, different complications with a Kock pouch may occur. METHODS: We present a case of a young female with signs of outlet obstruction several years after a Kock reservoir was performed because of complicated ulcerative colitis. The obstruction was caused by a fecal-coated GORE-TEX® sling that had penetrated through the nipple-valve base into the pouch. The mesenteric sling was introduced as a modification of the original Kock procedure to reinforce the efferent ileal segment, thus preventing nipple prolapse. The perforation site was closed with interrupted sutures and an ileostomy was performed. RESULTS: Three months thereafter, the ileostomy was closed and at a follow-up visit one year later the patient had no complaints and a well-functioning reservoir. CONCLUSION: If continence is desired after definitive ileostomy or if failure of the ileoanal reservoir occurs, a Kock pouch procedure still has a place in the surgical armamentarium of colorectal surgery. Many experts today do not use sling reinforcement maneuvers, and most of these procedures seem to work well without it.