Rolf Schlumpf

Incidence, Risk Factors, and Prevention of Biliary Tract Injuries during Laparoscopic Cholecystectomy in Switzerland

Abstract. Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) which may result in patient disability or death are reported to occur more frequently when compared to open surgery. The aim of this nationwide prospective study beyond the laparoscopic learning curve was to analyze the incidence, risk factors, and management of major BDI. During a 3-year period (1995–1997) 130 items of all LC data were collected on a central computer system from 84 surgical institutions in Switzerland by the Swiss Association of Laparoscopic and Thoracoscopic Surgery and evaluated for major BDIs. Simple biliary leakage was excluded from analysis. There were 12,111 patients with a mean age of 55 years (3–98 years) enrolled in the study. The overall BDI incidence was 0.3%, 0.18% for symptomatic gallstones, and 0.36% for acute cholecystitis. In cases of severe chronic cholecystitis with shrunken gallbladder, the incidence was as high as 3%. Morbidity and mortality rates were significantly increased in BDIs. BDI was recognized intraoperatively in 80.6%, in 64% of cases by help of intraoperative cholangiography. Immediate surgical repair was performed laparoscopically (suture or T-drainage) in 21%; in 79%, open repair (34% simple suture, 66% Roux-en-Y reconstruction) was needed. The BDI incidence did not decrease during the last 7 years. In 47%, BDIs were caused by experienced laparoscopic surgeons, perhaps because they tend to operate on more difficult patients. In conclusion, the incidence of major BDIs remains constant in Switzerland at a level of 0.3%, which is still higher when compared to open surgery. However, most cases are now detected intraoperatively and immediately repaired which ensures a good long-term outcome. For preventing such injuries, exact anatomical knowledge with its variants and a meticulous surgical dissecting technique especially in case of acute inflammation or shrunken gallbladder are mandatory.

Evaluation of intraoperative recurrent nerve monitoring in thyroid surgery.

Surgical exposure of the recurrent laryngeal nerve decreases the incidence of nerve injuries during thyroid surgery. Intraoperative neuromonitoring was introduced to facilitate identification and protection of the recurrent laryngeal nerve. Between February 1996 and June 2002 a total of 288 patients underwent thyroid surgery with intraoperative identification and intraoperative neuromonitoring of the recurrent laryngeal nerve. The overall incidences of permanent and transient recurrent nerve palsy (considered as a percentage of the nerves at risk) were 1.4% and 8.7%, respectively. Results were stratified in benign, malignant, and recurrent thyroid disease. Intraoperative function testing revealed a positive predictive value of 33% and negative predictive value of 99%. We concluded that the incidence of recurrent nerve lesions in benign, malignant, and recurrent thyroid disease was not lowered by the use of intraoperative neuromonitoring. Although an intact nerve can be verified by the neuromonitoring, the loss of nerve function cannot be reliably identified.

Long-Term Results of Hepaticojejunostomy for Benign Lesions of the Bile Ducts

BACKGROUND Hepaticojejunostomy has been the method of choice for the treatment of benign lesions of the extrahepatic bile ducts for years. In the era of minimally invasive and interventional techniques, a review of its long-term results is necessary to set the standard with which these new techniques have to be compared. METHODS A retrospective analysis was carried out for 51 patients (16 females, 35 males) aged 24 to 83 years (average 48 +/- 13) who had undergone hepaticojejunostomy for benign lesions at our institution between 1980 and 1989. Twelve patients had had up to 4 prior operations of their bile ducts. The main indications for operation were chronic pancreatitis (n = 33) and iatrogenic bile duct lesions (n = 15). If possible, a low end-to-side hepaticojejunostomy was performed. The Hepp-Couinaud approach was saved for high strictures and recurrences. All patients were reassessed by questionnaire at an average of 7.6 years (range 2 to 13) after the operation. RESULTS Four Hepp-Couinaud and 47 low hepaticojejunostomies were performed. Postoperative complications were seen in 17 patients (33%), 4 of whom had a reoperation. One patient died, for a mortality rate of 2%. The hospital stay averaged 24 +/- 17 days (range 8 to 90). Late complications developed in 13 patients (25%) 2 months to 6 years after the operation. Stenosis and cholangitis necessitated reoperation in 3 cases, cholangitis without stenosis was treated in 4, and other complications were seen in 5 cases. One patient died with a liver abscess, and 12 died of causes unrelated to the operation. When questioned, 31 of 35 patients were in good or very good condition. CONCLUSIONS Hepaticojejunostomy is a safe and reliable method for the treatment of benign lesions of the bile ducts even in young patients in need of a long-term biliary bypass.

In situ repair of aortobronchial, aortoesophageal, and aortoenteric fistulae with cryopreserved aortic homografts

PURPOSE The surgical treatment of fistulae that originate from aortic aneurysms or prosthetic aortic grafts carries a high mortality rate. We investigated whether in situ repair with cryopreserved aortic homografts would improve the outcome. METHODS Between April 1994 and June 1996, 11 patients (mean age, 62 +/- 10 years) with aortobronchial, aortoesophageal, or aortointestinal fistulae originating from mycotic aneurysms (five of 12) or prosthetic aortic grafts (six of 12) underwent in situ replacement of the thoracic (seven of 10) or abdominal (four of 10) aorta with homografts. Emergency surgery was performed in eight of 11 patients (73%). RESULTS The hospital mortality rate was 9%; there was one sudden cardiac death on the seventh postoperative day. The mean hospital stay was 42 +/- 26 days (range, 21 to 90 days). After surgery, antibiotics were given for 38 +/- 6 days (range, 28 to 42 days). Neither reinfection, suture line rupture, nor anastomotic aneurysms were observed by magnetic resonance angiography, computed tomography, angiography, or transesophageal echocardiography after 14.3 +/- 8.2 months (range, 6 to 31 months). In one patient, percutaneous vascular stent placement was necessary after 18 months for an anastomotic stenosis of a thoracic homograft. CONCLUSIONS In situ repair with cryopreserved aortic homografts seems to be a promising step in the treatment of aortobronchial, aortoesophageal, and aortointestinal fistulae. This technique has a low operative mortality rate and may prevent reinfection.

Pancreas retransplants compared with primary transplants.

The improved results with pancreas transplantation in general, and the emerging evidence that the procedure favorably influences the course of secondary diabetic complications, given an impetus to retransplant patients whose initial graft has failed. In order to determine whether a pancreas retransplant policy is justified, we analyzed the results at our own institution. From 1978 through 1989, 327 pancreas transplants were performed in 261 patients, including 259 primary (79%) and 68 retransplants (21%) after a previous one failed (including 2 primary transplants performed elsewhere), with 48 second (15%), 18 third (5%), and 2 fourth (1%) transplants. The surgical techniques used in the 261 primary PxTxs were open-duct free drainage into the peritoneal cavity in 15 recipients, of whom 3 (20%) were retransplanted: duct occlusion in 34, of whom 9 (26%) were retransplanted intestinal drainage in 78, of whom 23 (29%) were retransplanted; and bladder drainage in 134, of whom 13 (10%) were retransplanted. The surgical techniques used for the 68 pancreas retransplants were duct occlusion in 11 (10 second, 1 third), intestinal drainage in 12 (9 second, 3 third), and bladder drainage in 45 (29 second, 14 third, and 2 forth); bladder drainage has been used nearly exclusively for the most recent pancreas retransplants. The recipient categories in the 261 primary transplants were pancreas alone in 115, of whom 29 (25%) were retransplanted, pancreas after kidney in 81, of whom 17 (21%) were retransplanted, and simultaneous pancreas and kidney transplants in 63, of whom 2 (3%) were retransplanted. Of the 68 pancreas retransplants, 32 (47%) were pancreas alone (26 second, 6 third), 24 (35%) were pancreas after kidney (17 second, 6 third, 1 fourth), and 12 (18%) were simultaneous pancreas and kidney (5 second, 6 third, 1 fourth). Overall patient survival rates were similar (P = 0.48), at 1 month (actual [98% after primary and 94% after retransplantation]) and at 1 year (actuarial [91% vs. 89%]). Overall graft functional rates were also similar, at 1 month (actual [76% for all primary and 79% for all retransplants - P = 0.9]), and at 1 year (actuarial [46% vs. 43% - P = 0.9]). Causes of graft losses at 1 months were similar for primary (18% were technical failures, 6% were rejected) and retransplant (16% were technical failures, 3% were rejected) cases.(ABSTRACT TRUNCATED AT 400 WORDS)

A novel dextran 40-based preservation solution

Although the University of Wisconsin (UW) solution has become the standard solution for the preservation of kidneys for transplantation, the importance of the colloid hydroxyethylstarch (HES), one of the key compounds of the UW solution, has been questioned repeatedly. It is now established that HES is not necessary for routine kidney preservation. However, colloids may still be advantageous in UW like solutions for the purpose of multiorgan procurements and the preservation of organs from marginal donors. It has been shown in various experimental models that dextran 40 may successfully substitute for HES. Dextran 40 is not only cheaper but also has a variety of biological effects that may be beneficial during the graft reperfusion phase. The aim of this clinical study was to examine the efficacy of a dextran 40-based preservation solution (Dex-PS) for its use in human kidney graft preservation and to compare the transplantation results with kidneys preserved with UW solution. A total of 87 kidneys were preserved with Dex-PS and matched with 87 kidneys preserved with UW solution. Both groups were comparable in terms of donor and recipient characteristics and both had a high proportion of kidneys from nonheart-beating donors. Patient survival and graft survival after 1 year were 95% and 86% for the Dex-PS group and 94% and 90% for the UW group, respectively (P=NS). Primary nonfunction, delayed graft function, postoperative need for dialysis, and follow-up of serum creatinine were statistically comparable between these two groups. We conclude that dextran 40 can safely replace HES in UW solution for the purpose of clinical kidney preservation. There were no statistically detectable differences in graft performance between the kidneys preserved with UW and those preserved with Dex-PS.

Treatment of the Morbidly Obese Patient with Laparoscopic Adjustable Gastric Banding

Laparoscopic gastric banding is a recently introduced operation for the treatment of morbid obesity. Its main advantages are minimal invasiveness of the operative procedure, postoperative adjustabilit

Kidney procurement from non-heartbeating donors: transplantation results

To overcome the shortage of kidneys (kdns) available for transplantation we reactivated kdn procurement from non-heartbeating donors (NON-HBD). In this study, we reviewed our results with 34 kdns from NON-HBD, transplanted between 1985 and 1991, and compared these with 34 control kdns procured from heartbeating donors (HBD) matched for age, sex, primary graft or retransplant and transplant year. There was no difference in cold ischemia time, preservation solutions used, duration and type of preoperative dialysis, number of HLA mismatches and serum antibody levels between the two groups. The only significant findings were a lower diuresis in the last hour in the donors in the NON-HBD group, and a significantly higher serum creatinine level compared to the HBD group. The 1-year patient and graft survival rates were 89.4% and 84.9% for the HBD group, and 78% and 76.1% for the NON-HBD group respectively. There was need for dialysis support in the first posttransplant week in 10 out of 34 (29%) recipients in the HBD and 17 out of 34 (50%) recipients in the NON-HBD group. Primary non-function was observed in 1 of 34 (3%) recipients in the HBD group versus 3 of 34 (9%) in the NON-HBD group. None of the differences were statistically significant. There was also no difference in average serum creatinine levels at days 1, 3, and 7, at 1 month and at 1 year between the HBD and NON-HBD groups. In the NON-HBD group 6 of 34 kdns (18%), 5 of which were retransplants, showed vascular rejection, 5 of them associated with haemolytic uremic syndrome (thrombotic microangiopathy); 2 of these 6 kdns recovered, and 4 failed (2 with primary non-function). This important observation needs to be investigated further. The results is this study showed, however, that good short- and long-term results can be achieved with kdns from NON-HBD. We concluded that organ procurement from NON-HBD is an adequate approach to an important cadaver donor source that in general is not effeciently used, but could significantly increase the number of kdn grafts in most transplant programs.

New anastomosis technique for (laparoscopic) instrumental small-diameter anastomosis

This study presents a new technique for visceral anastomosis. The principle consists of connecting the two parts to be anastomosed around a reabsorbable stent which is transluminally introduced into a small-diameter viscus, where it is fixed. Advancing a larger tube along the axis of the machine, the larger, perforated viscus is inverted and pulled over the stent, and finally a rubber band pops off the machine endoluminally in order to fix the intestinal walls in seroserosal contact onto the stent. To evaluate this “micro” anastomosis, a biliary bypass (choledochojejunostomy and roux-en-y-loop) was performed in ten pigs. Nine of ten animals showed biliary bypass with good runoff in contrast radiography and completely reabsorbed stent after a 3-month follow-up. Weight gain, bilirubin, and alkaline phosphatase were normal. This technology demonstrates a safe and quick way to perform instrumental “micro” anastomosis without remnant foreign material.

Sterno-laparotomy and extracorporeal circulation for liver transplantation after repeat-surgery for Budd-Chiari syndrome.

The surgical management of two patients undergoing living transplantation for Budd-Chiari syndrome is reported. Mesenteriocaval shunt had previously been performed in both cases, followed by transcaval liver resection and hepatoatrial anastomosis after 3 and 5 years, respectively. Liver transplantation was necessitated by deteriorating liver function with portal hypertension and recurrent bleeding. The successful operation was performed via sternolaparotomy. Atrioatrial anastomosis was constructed during cardiopulmonary bypass, considerably simplifying the technical procedure and dramatically reducing blood loss.