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BACKGROUND AND OBJECTIVE The preoperative investigation for choledocholithiasis in patients undergoing elective laparoscopic cholecystectomy is still a matter of debate. PATIENTS AND METHODS In a prospective clinical trial the accuracy of intravenous cholangiography (IVC), ultrasonography and liver function tests in the preoperative diagnosis of choledocholithiasis was assessed in 98 patients undergoing elective cholecystectomy. Only patients with uncomplicated cholecystolithiasis considered to be at low risk for having bile duct stones were investigated. A 2-year follow-up clinical survey (mean) was performed in 92 of the 98 patients to investigate the occurrence of postoperative choledocholithiasis (gold standard: clinically manifest choledocholithiasis). RESULTS In this patient cohort the incidence of choledocholithiasis was found to be 5.1%. Among the three diagnostic tests IVC proved to be more accurate with higher sensitivity and a better positive predictive value than ultrasonography and liver function tests. The sensitivity for IVC was 100% compared to 20% for ultrasonography and 40% for liver function tests, respectively. The positive predictive value for IVC was 83.3% in comparison to 20% for ultrasonography and 25% for liver function tests. Mild side effects caused by intravenous contrast media were observed in 2.0%. During a mean postoperative follow-up of 2 years no clinically manifest and initially overlooked choledocholithiasis could be detected in the 92 investigated patients. CONCLUSION IVC is a reliable method to detect unsuspected common bile duct stones and should be used in the preoperative diagnosis prior to elective laparoscopic cholecystectomy. IVC may play a role in decreasing the rate of preoperative ERCP or intraoperative cholangiography in these patients.

Hepatocellular carcinoma (HCC) is a highly malignant tumor with a poor prognosis. The success of its established treatment modalities is frequently limited by the advanced stage of the tumor at the time of diagnosis. Therefore, it is important to understand the mechanisms that control its growth behavior. In the present study, we review some aspects of molecular and cellular processes involved in growth control and metastatic potential of HCC. These include some growth factors and their receptors, oncogenes and tumor suppressor genes, and factors that control angiogenesis and extracellular matrix formation. These factors may be important targets for novel therapeutic approaches in the future.

Background: Blunt or penetrating truncal traumas can result in diaphragmatic rupture or injury. Because diaphragmatic defects are difficult to diagnose, those that are missed may present with latent symptoms of obstruction of herniated viscera. Methods: A chart review of all patients admitted with late presentations of postraumatic diaphragmatic hernias from 1980 to 1996 was undertaken. Results: Ten patients with posttraumatic diaphragmatic hernias were treated in this specified period. There were six males and four females with a mean age of 65 years. Eight patients sustained blunt truncal traumas and two patients sustained penetrating truncal traumas. The hernias occurred in two patients on the right and in eight patients on the left side and contained the liver (n = 2), bowel (n = 10), stomach (n = 4), omentum (n = 5), or spleen (n = 1). The time until the hernias became clinically symptomatic ranged from 20 days to 28 years. In all but one patient, either routine chest roentgenograms or upper gastrointestinal contrast studies were diagnostic. All 10 patients underwent laparotomy (n = 9) or thoracotomy (n = 2) with direct repair of the diaphragmatic defect. One patient died 3 days after the operation, representing a mortality of 10%; the morbidity was 30%. Conclusion: Initial recognition and treatment of diaphragmatic rupture or injury is important in avoiding long-term sequelae.

SummaryTwenty patients with unresectable hepatocellular carcinoma (HCC) were followed up to 5 years after transarterial radiotherapy with 90Y-resin particles. Diagnostic radioembolizations of 99mTc-macroaggregates facilitated scintigraphic assessment of activity distribution, dose evaluation and final procedural verification. The overall survival rates were 56, 38 and 14% (after 1, 2 and 3 years, resp.). Patients with unifocal HCC and a single feeding artery (n = 7) even presented 83, 67 and 40% (2 alive after 2.75 and 4 years). With multiple arteries (n = 7), the longest survival was 26 months. Patients with multifocal HCC survived up to 33 months after selective radioembolization. Quality of life was improved in all. Survival was positively correlated with absorbed dose but residual/recurrent tumour occurred even after ≥300 Gy. Post-treatment symptoms were minimal (35 applications), pulmonary shunt rates were correctly predicted and pulmonary complications avoided.

Hepatocellular carcinoma is a common malignancy globally with increasing incidence and significant cancer mortality. Delayed detection leads to a poor prognosis with median survival of < 10 months. Only very few patients qualify for a resection or transplantation. Even local treatments are only useful in very few selected patients. No strong evidence exists on beneficial effect of any chemotherapy, hormonal therapy, or immunotherapy in advanced HCC-patients. Thus finding effective systemic treatments for non-resectable HCC has become a great challenge. HTI-286 is a synthetic analogue of hemiasterlin and depolymerises microtubules. In several human xenograft models HTI-286 has shown significant antitumor activity. We have analyzed antitumor effect of HTI-286 alone or in combination with CCI779 on hepatic tumor cells in an in-vitro and in-vivo model. Proliferation of all hepatic tumor cells (MH, Hep3B und HepG2) was inhibited in-vitro. Primary human hepatocytes were not affected by HTI-286. A significant tumor reduction was seen in-vivo in the HTI and HTI/ CCI779 group. HTI inhibits tumor cell proliferation in-vitro and in-vivo. CCI779 seems to have an additive effect on tumor reduction. HTI is to be considered as a promising drug in the treatment of advanced HCC.

The feasibility of one whole liver chemoembolization (CE) procedure with Angiostat, a vasoocclusive collagen, mitomycin, doxorubicin, and cisplatin was evaluated in eight patients with unresectable colorectal carcinoma metastatic to the liver and good performance status. One heavily pretreated patient showed a partial response in the liver lasting 188 days. Five patients had stabilization of the disease for 85-150 days. The side effects of the treatment were considerable with a fatigue syndrome lasting up to eight weeks, chemical and ischemic hepatitis, severe thrombopenia (WHO grade 4 in 2 pts) and icterus being the most disturbing toxicities. We recommend to restrict CE to patients with a life expectancy of more than 4-6 months confined to protocols, which evaluate efficacy, toxicity and influence on quality of life of CE with various cytotoxic drugs. We further suggest to perform staged unilobar CE at 4- to 6-week intervals rather than whole liver CE.

The increasing knowledge of the anatomy and function of the liver made the surgical resection of liver metastases currently to the therapy of choice. Although liver metastasis is an advanced stage in tumor-progression, surgery achieves the best long-term results due to a better understanding of the carcinogenesis (i.e. micrometastases) and the prognostic risk factors. This study summarizes the results of 109 resections of colorectal and non-colorectal liver metastases during a period of 59 months at our department. Four different surgical techniques (extended hepatectomy vs. segmental resection vs. atypical resection vs. biopsy) were investigated. For resections a tumour-free resection margin of at least 10 mm was always attempted to achieve. The accumulated morbidity of all techniques together was 23%. Although the morbidity was higher for extended resections (Encephalopathy 16% vs. 2.3% for segmental resections, Liver insufficiency 23% vs. 4.7%), compared to the limited resection procedures, the long-term survival improved. The overall mortality was 2.7%. Survival was higher in patients with resection of colorectal than non colorectal metastases. Our results indicate that liver resection, under observance of the anatomical and functional margins (i.e. an adequate resection margin), is the only potentially curative therapy for liver metastases. An extensive formal resection, although inducing a higher perioperative morbidity, is superior to the limited resection techniques and results in an increased long-term survival. One reason is the increased probability of co-resection of preoperatively undetected local micrometastases.

Connective tissue growth factor (CTGF) belongs to a family of factors that regulate fibrogenesis and wound healing. While the significance of transforming growth factor beta (TGF-beta) in liver fibrosis is well established, the role of CTGF in fibrosing hepatopathy is still unknown.CTGF was analyzed in 10 normal and in 16 cirrhotic liver tissue samples. Northern blot analysis was used to examine the concomitant expression of CTGF and TGF-beta1 mRNAs, and the cellular localization of CTGF mRNA was studied by in situ hybridization. For identification of myofibroblasts and activated hepatic stellate cells, alpha-smooth muscle actin (alpha-SMA) immunohistochemistry was used.Northern blot analysis showed 6.5-fold enhanced expression of CTGF mRNA and 7.8-fold enhanced expression of TGF-beta1 mRNA in liver cirrhosis in comparison with normal controls (p0.01). By in situ hybridization, CTGF mRNA was detectable in only a few spindle cells in the portal tracts in normal liver samples. In contrast, there was strong expression of CTGF mRNA in fibroblasts and myofibroblast-like cells present in fibrous septa surrounding the cirrhotic nodules, in stellate cells, in endothelial cells and in mesenchymal cells around ductular proliferations, and in ductular epithelial cells. There was a strong correlation between CTGF mRNA and TGF-beta1 mRNA as well as the degree of fibrosis (p0.01).Overexpression of CTGF in liver cirrhosis, especially in fibroblasts/myofibroblasts and stellate cells, suggests that this novel factor may play an important role in hepatic fibrosis.

The preoperative investigation for choledocholithiasis in patients undergoing elective laparoscopic cholecystectomy is still a matter of debate.In a prospective clinical trial the accuracy of intravenous cholangiography (IVC), ultrasonography and liver function tests in the preoperative diagnosis of choledocholithiasis was assessed in 98 patients undergoing elective cholecystectomy. Only patients with uncomplicated cholecystolithiasis considered to be at low risk for having bile duct stones were investigated. A 2-year follow-up clinical survey (mean) was performed in 92 of the 98 patients to investigate the occurrence of postoperative choledocholithiasis (gold standard: clinically manifest choledocholithiasis).In this patient cohort the incidence of choledocholithiasis was found to be 5.1%. Among the three diagnostic tests IVC proved to be more accurate with higher sensitivity and a better positive predictive value than ultrasonography and liver function tests. The sensitivity for IVC was 100% compared to 20% for ultrasonography and 40% for liver function tests, respectively. The positive predictive value for IVC was 83.3% in comparison to 20% for ultrasonography and 25% for liver function tests. Mild side effects caused by intravenous contrast media were observed in 2.0%. During a mean postoperative follow-up of 2 years no clinically manifest and initially overlooked choledocholithiasis could be detected in the 92 investigated patients.IVC is a reliable method to detect unsuspected common bile duct stones and should be used in the preoperative diagnosis prior to elective laparoscopic cholecystectomy. IVC may play a role in decreasing the rate of preoperative ERCP or intraoperative cholangiography in these patients.

Congenital cystic liver disease represents a rare entity and only in 5%-20% the cysts cause symptoms or complications that demand therapy. In the past decades several therapeutic approaches have been developed with variable long-term outcome. We report herein our results and the postoperative outcome of 26 patients treated from 1987 to 1998 in our department because of symptomatic or complicated congenital cystic liver disease. In cases of symptom-producing solitary liver cysts our therapy of choice was laparoscopic fenestration. In cases of adult polycystic liver disease we mostly performed partial hepatic resection and fenestration. Both therapeutic approaches have proven a favorable long-term outcome. However, some types of adult polycystic liver disease possess a high risk of reappearance. Preoperative pathomorphological assessment of polycystic liver disease should be performed to choose the operative procedure in relation to the expected recurrence rate. Because of the progresses made in dialysis therapy and transplantation surgery in patients with adult polycystic kidney disease, an increase of patients with symptomatic polycystic liver disease has to be expected in the near future.

Giant liver hemangiomas are defined as hemangiomas with a diameter of more than 4 cm. They often require surgery due to bleeding tendencies or local compression. Between 1994 and 1998 we operated 11 patients with giant hemangiomas (median diameter 5.8 cm, range 4-12.5 cm). Average age was 50 years (range 23-85 years). 6 patients complained of pain, 1 patient sustained a bleeding. 7 hemangiomas were enucleated, 2 segmentally resected, 1 patient underwent a hemihepatectomy. 1 patient suffered from a bile leakage. Mortality was 0%. We conclude that clinically symptomatic liver hemangiomas can be safely resected. In a right sided localisation a enucleation has the best parenchyma sparing effect, in left sided locations a segmentectomy or bisegmentectomy can be performed with little blood loss.

We intend to analyze if additional treatment concepts are necessary in any case as a part of the standard therapy next to the well established principle of source control in the treatment of secondary peritonitis.A treatment concept with early intervention, source control and extensive intraoperative lavage (20-301) should be evaluated as a standard procedure in a prospective survey. Additional treatment concepts will be applied only for special reason (on demand).From 11/1993 to 9/1997 241 patients with diffuse peritonitis were treated with the concept mentioned above. Additional treatment concepts as continuous postoperative lavage (n = 20) and staged lavage (n = 4) were applied as primary treatment in 24 patients only (10%), mainly for impossibility of source control and evisceration. Source control at the initial operation was possible in 216 patients (90%). Due to secondary evisceration 3 patients had to undergo laparostomy for staged lavage later. Severity of peritonitis was determined according to the Mannheim Peritonitis Index (median 26, range 15-43). The primary causes of peritonitis were perforation, leakage and abscess after operation (n = 56), followed by diverticular (n = 42) and gastric or duodenal perforation (n = 39). The hospital mortality rate was 14% in the whole group, and the postoperative morbidity rate was 39%.Due to progress in intensive care and antibiotic treatment only a few patients (ca. 10%) need additional therapies such as postoperative or staged lavage. Surgical source control in combination with intraoperative lavage is sufficient in most of the patients with diffuse peritonitis.

Acute hemorrhage in the course of chronic pancreatitis is the most serious and challenging complication, and its treatment has been the subject of controversy for years. We relate our experience in the management of this complication by superselective microcoil embolization. Five patients with acute hemorrhage resulting from chronic pancreatitis between 1994 and 1997 were included in this study. All patients were men with a median age of 44 years (range, 29-59 years). The bleeding occurred into a pseudocyst in all patients, with the splenic artery as feeding vessel. In all instances, the bleeding was successfully controlled by superselective microcoil embolization. Two patients underwent subsequent uneventful elective pseudocystojejunostomy. There was no mortality or morbidity, and no rebleeding occurred during a median follow-up of 22 months (range, 8-36 months). In appropriate patients, diagnostic angiography and superselective microcoil embolization may obviate the need for emergency surgery and should be considered as treatment alternative.

Definition: Periampullary carcinomas are rare and constitute a special entity, as diagnosed earlier and having a better prognosis than other duodenal tumors. Methods: In the present study, we retrospectively reviewed the medical records of 16 patients with periampullary carcinomas over 10 years. Results: 16 patients, 10 men and 6 women (median age 66.7 years, range 42-80) had a malignant periampullary tumor. Initial symptoms were jaundice (88%), weight loss (69%), nausea and vomiting (50%) and abdominal pain (38%). Gastro-duodenoscopy, ERCP, ultrasound and CT scan were the most useful diagnostic tools. Histologically all the tumors were adenocarcinomas and solitary tumors. 91% were stage pT1 or pT2 tumors, localized in the duodenal wall without any infiltration of the pancreas. 36% of the tumors had metastasized either in lymph nodes or distant organs at diagnosis (18% pN1, 18% pM1). Resectability rate was 81%, curative resection was achieved in 62%. The operations performed were pancreatico-duodenectomy (n = 8), local tumor resection (n = 5) and palliative bypass (n = 3). Morbidity and reoperation rate were 37.5% and 18.8%, respectively; 30-day mortality was 0%. The 1- and 5-year survival rates were 58.3% and 33.3%, respectively. Conclusions: Compared to carcinomas of the small bowel or the exocrine pancreas periampullary carcinomas have a far better 5-year survival rate of more than 30%. Aggressive diagnostic workup in case of the leading symptom jaundice and radical operative therapy are key factors to achieve this goal.

Adenocarcinomas of the bifurcation of the hepatic ducts (Klatskin tumors) are a relatively rare cause of obstructive jaundice. Differential diagnosis includes other neoplastic lesions, sclerosing cholangitis, Mirizzi's syndrome and benign strictures. We present a 46 year-old white female with a 2 month history of epigastric pain and progressive jaundice. Endoscopic retrograde cholangiopancreaticography (ERCP) revealed a filiform stenosis of the right hepatic duct and an obstructed left hepatic duct, an image strongly suggestive of a Klatskin tumor. The correct diagnosis was achieved, however, by percutaneous transhepatic cholangiography (PTC), which disclosed a gallstone at the common hepatic duct bifurcation and multiple small concrements in the left hepatic duct. After endoscopic removal of the gallstones in the biliary tree and laparoscopic cholecystectomy, the patient was discharged on the third post-operative day. Protuberant tumors and round biliary stones may be confused at ERCP.

Laparoscopic cholecystectomy is considered as the new gold standard operation for removal of the gallbladder, and has several advantages over the traditional open cholecystectomy. However, in the last few years there is an increasing number of case reports of port site metastases following laparoscopic cholecystectomy for unsuspected carcinoma of the gallbladder. Two case reports of trocar site metastases are presented, and they further highlight the concern of the role of minimal invasive surgery in the presence of unsuspected carcinoma of the gallbladder. In this review we speculate on the mechanisms which may be responsible for metastatic deposits during laparoscopic cholecystectomy and suggest certain recommendations.

Only 34 cases of primary cystic duct carcinoma have previously been published in the literature. Most of these cases presented with upper abdominal pain and a palpable mass in the right upper quadrant due to gallbladder hydrops or cholecystitis. We report a case of cystic duct carcinoma with the clinical presentation of obstructive jaundice. The patient was treated by cholecystectomy, resection of the common bile duct and a Roux-en-Y hepaticojejunostomy. An extended lymph node dissection was not performed. Fourteen months after the operation the patient died with local carcinoma recurrence. A literature review comparing clinical signs, surgical treatment, and outcome of 14 Japanese and 21 reported Western cases, including ours, was performed. Extended lymph node dissection in addition to combined resection of the gallbladder and ductus hepaticocholedochus appears to offer a better prognosis and larger survival, including the chance of potential cure.

The authors report on a case of a solitary liver abscess due to Listeria monocytogenes in a 53-year-old diabetic white male and review all published cases of solitary listerial abscesses of the liver. L. monocytogenes is a rare cause of solitary liver abscess which occurs in elderly patients with diabetes mellitus. The clinical signs are variable and often mimic malignancy, with epigastric pain, night sweats and weight loss. Prevalent features are poor control of glycemia, temperature up to 38.5 degrees C and elevated alkaline phosphatase. Optimal treatment includes percutaneous drainage of the hepatic abscess and antibiotic therapy with an aminopenicillin or trimethoprim/sulfamethoxazole. Outcome of the reviewed patients was favourable with no mortality and no relapse of the disease.

Down-regulation of KAI1 expression has been shown to be associated with formation of metastases or disease progression in prostate and pancreatic cancer. In the present study we analyzed the expression pattern of KAI1 in metastatic and nonmetastatic hepatocellular carcinomas (HCCs) in comparison with normal livers to evaluate whether alteration of KAI1 also facilitates the metastatic ability in this malignancy. Thirty-nine primary HCCs and 10 normal liver tissue samples were studied for KAI1 messenger RNA (mRNA) expression with use of Northern blot analysis and in situ hybridization. By Northern blot analysis, moderate to strong KAI1 mRNA expression was present in normal liver samples. In contrast, KAI1 mRNA expression in tissue samples of primary HCCs was markedly decreased compared with normal controls. The normal/tumor ratio of KAI1 mRNA expression was 2.6:1 (P.01). Primary HCCs that gave rise to metastasis showed significantly lower KAI1 mRNA levels than nonmetastasized HCCs (P. 05). As seen by in situ hybridization, moderate to strong cytoplasmic KAI1 mRNA staining was present in almost all normal hepatocytes. Bile ducts, blood vessels, and connective tissue showed no or only faint KAI1 mRNA expression in the normal liver samples. In nonmetastatic HCCs, the cancer cells exhibited in situ hybridization signals that were similar to the normal controls. In contrast, most of the primary HCC cells in samples with metastases showed only faint or moderate KAI1 mRNA expression predominantly in the perinuclear regions. When KAI1 mRNA expression of primary hepatocellular cancer cells was compared with metastasized cancer cells in lymph nodes, with intrahepatic satellite metastasis, or with peritoneal metastasis in the same patients, significantly lower (P.01) KAI1 mRNA levels were present in the metastasized HCC cells. Reduced KAI1 mRNA in HCC cells seems to influence their metastatic ability and thereby enhances the malignant potential of HCC.

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.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.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.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.

Worldwide, hepatocellular carcinoma is one of the most common intra-abdominal malignancy. It occurs mostly in patients who are carriers of the hepatitis B or C virus and/or have liver cirrhosis. There is no screening-test for early recognition of the development of liver cancer and this delays often an accurate diagnosis and early treatment. Resection is the best form of treatment offering a chance of cure. In the last decades, considerable progress has been made in the field of liver diagnostic and operative techniques for liver resection. This has been followed by an increase in the resection rate of patients with malignant liver tumours and by a decrease in postoperative morbidity and mortality. Nowadays, after curative resection, 5-year survival rates up to 30% can be achieved. Promising results are also obtained by new adjuvant therapeutic modalities demonstrating improvement in survival. Therefore, in the field of malignant liver tumours there is no more space for therapeutic nihilismus.

30–40% der Patienten mit chronischer Pankreatitis entwickelt einen entzundungsbedingten Pankreaskopftumor, der zur Stenose des D. pancreaticus/choledochus, Duodenums und der retropankreatischen Gefase fuhren kann. In der Vergangenheit wurde bei diesen Fallen eine partielle Duodenopankreatektomie durchgefuhrt, die das Therapieziel bei dieser benignen Erkrankung uberschreitet. Im Video wird die duodenumerhaltende Pankreaskopfresektion, die von Prof. Beger 1972 inauguriert wurde, mit den Therapieergebnissen bei 298 Patienten dargestellt. Die postoperative Morbiditat betrug 28,5% mit einer Klinikletalitat von 1%. Im Follow-up (im Median 6 Jahre) waren 88% der Patienten dauerhaft vollig schmerzfrei oder hatten nur milde Schmerzschube, 63% der Patienten konnten ihre Arbeit wieder aufnehmen. Vorteile dieser Operationsmethode gegenuber der Whippelschen Operation sind: Entfernung des Krankheitsherdes/Schrittmachers der Erkrankung ohne Verlust gesunder Organe, Erhaltung der Duodenalpassage mit niedriger Neuinzidenz eines Diabetes mellitus (2%), sichere Operationsmethode mit niedriger Morbiditat und Lealitat und im Langzeitverlauf hohe Schmerzfreiheitsrate mit beruflicher Rehabilitation. Die duodenumerhaltende Pankreaskopfresektion stellt bei Patienten mit chronischer Pankreatitis und einem entzundlichen Pankreaskopftumor eine wichtige chirurgische Alternative dar.

Cervical leakage, occurring on average in 20-50% of the patients, is one of the major causes of morbidity following oesophagectomy for cancer. We report on a new technique of gastroplasty, namely fundus rotation gastroplasty which was used in 53 patients. There were 49 patients with oesophageal cancer and 4 with benign lesions. Hospital mortality was 5.7% (3/53) and the leakage rate 7.5% (4/53). The advantages of fundus rotation gastroplasty over conventional gastroplasty are the better blood supply and the greater length of the gastric tube. Controlled clinical trials will be necessary to confirm the advantages of fundus rotation gastroplasty versus conventional gastroplasty.

Over the last 20 years, unifocal functionally autonomous nodes (UFA) of the thyroid have accounted for more than one third of all patients with hyperthyroidism in the former iodine-deficient and goiter-endemic region of Bern. This situation calls for a special diagnostic approach, i.e. etiologic diagnosis of any solitary nodule and careful consideration of therapy in contrast to regions with iodine excess where UFA is very rare, such as the USA. Therapy is recommended even where hyperthyroidism is still latent (blocked TRH test, normal TT3 and TT4) and reliably leads to subjective and objective improvement even in oligosymptomatic individuals. The safe and easy radioiodine therapy (RIT) is preferred in elderly patients with associated conditions. Surgical resection is recommended chiefly where malignancy is suspected or RIT is technically inappropriate. Both methods produce prompt eradication of the source of hyperthyroidism. The most frequent complication is hypothyroidism requiring lifelong follow-up.

Duodenum-preserving resection of the head of the pancreas was developed 25 years ago by Beger. This procedure is indicated in patients suffering from chronic pain in combination with inflammation of the head of the pancreas, common bile duct obstruction, pancreatic duct obstruction and/or obstruction of the retropancreatic vessels. At the Inselspital in Berne, 74 patients underwent this operation between 1993 and 1996. The median length of the operation was 380 min, with the need for transfusion in a median of 0 units (0-6). There was no postoperative mortality. Total postoperative morbidity was 13%. One patient needed relaparotomy on day 17 for small bowel obstruction. Median length of hospital stay was 11 days. Postoperatively, two patients developed diabetes. Duodenum-preserving resection of the head of the pancreas represents an organ-preserving principle of surgery. This procedure treats the complications of chronic pancreatitis and provides long-term pain relief in more than 80% of patients.

Entrapment neuralgia after open and laparoscopic hernia repair occurs in about 1-2 per cent of patients. If the pain persists accurate identification of the nerve involved and surgical treatment is an option. Entrapment neuralgia of the genital branch of the genitofemoral nerve and ilioinguinal nerve occurs, but damage to the femoral branch of the genitofemoral nerve, the lateral femoral cutaneous nerve and the femoral nerve is also described. This paper reports an endoscopic technique for neurectomy.A balloon catheter is inserted bluntly into the lower retroperitoneum and insufflated to create a work space. Neurectomy is performed under endoscopic guidance.Three men with a mean age of 39 years were treated using this technique. A neurectomy of the genitofemoral nerve was performed in all three and in one neurectomy of the ilioinguinal nerve was also done. The mean operating time was 70 min and all the patients were completely pain-free after surgery. All patients were discharged within the first 2 days after operation and there were no complications.This retroperitoneal endoscopic technique is proposed as a new surgical approach for treating entrapment neuralgia. It is simple and effective at relieving symptoms.

Leakage of oesophagogastric anastomosis has been associated with poor perfusion of the gastric tube. The authors recently developed a new form of gastroplasty, preserving not only the arterial arcade along the greater curvature, but also the lesser curvature. In this study their first clinical experience with that gastric tube is reported.Thirty-five patients undergoing either oesophagectomy or laryngopharyngo-oesophagectomy for malignant lesions and substitution of the oesophagus with a funds rotation gastroplasty were included. Patient outcome, including anastomotic leak, hospital mortality and morbidity rates, were studied prospectively.Hospital mortality rate was one of 35 and anastomotic leak (one minor, one moderate) was found in two patients with no subsequent mortality. Further major morbidity included pulmonary dysfunction in the form of acute respiratory distress syndrome (ARDS) in seven patients. Mean (s.e.m.) hospital stay was 27(19) days, and 21(9) days in patients who did not develop ARDS.Fundus rotation is a new method of gastroplasty that allows safe anastomosis of the tube with the remaining oesophagus or pharynx and is associated with a low leak rate even at high cervical levels.

Der postoperative Verlauf nach Osophagusresektion wird haufig kompliziert durch pulmonale Komplikationen und Leckagen der osophagogastralen Anastomosen. Im Bereich des Halses heilen diese Anastomosenlecks in der Regel problemlos ab, im Thorax gehoren sie jedoch zu den gefurchtetsten Komplikationen der Osophagusresektion. Neben technischen Problemen verursachen schlechte Durchblutung und mangelnde Magenschlauchlange diese Anastomosenlecks [1, 2]. Mit einer von uns kurzlich entwickelten Technik, bei welcher die gesamte Magenfunduskappe erhalten und lediglich ein kleiner Teil der Magenkurvatur reseziert wird [3], konnen ausgezeichnete Durchblutungsverhaltnisse und eine grose Magenschlauchlange bei erhaltenem grosen Magenrestreservoir erreicht werden [4]. In dieser tierexperimentellen Studie wurden die anatomischen und mikrozirkulatorischen Besonderheiten dieser Fundusrotations-Magenplastik (FRMP) mit konventioneller Magenplastik (KMP) mit Kleinkurvaturresektion und einer reversed Gastroplasty (RMP) [5] verglichen.

The value of diagnostic laparoscopy to improve tumor staging in patients with pancreatic and periampullary cancer is still a matter of controversial discussion, especially with regard to whether diagnostic laparoscopy can identify patients in whom a laparotomy can be avoided due to metastases. To answer this question, all patients who underwent operations for pancreatic cancer (n = 97) or periampullary cancer (n = 30) between 11/1993 and 12/1995 were evaluated. Only 10% of the patients with periampullary/pancreatic cancer and 13% with pancreatic cancer could avoid laparotomy through diagnostic laparoscopy. Due to these low numbers, a diagnostic laparotomy cannot be recommended in general in patients with pancreatic and/or periampullary cancer on economic grounds and because of the risk of trocar metastases.

Intrasplenic pseudocyst is a rare form of a late complication of chronic pancreatitis. We report the case of a 30-year-old man with an intrasplenic pseudocyst associated with chronic alcoholic pancreatitis. The patient was admitted with the third acute phase of chronic relapsing pancreatitis. Abdominal US and CT showed a large cyst in the pancreatic tail with involvement of the spleen. ERCP revealed marked irregularities of the main pancreatic duct without communication to the large cyst and a narrowing of the distal common bile duct by chronic pancreatitis of the head of the pancreas. Organ preserving surgical treatment with duodenum- preserving resection of the head of the pancreas combined with distal pancreatectomy and splenectomy was performed. This procedure may be indicated in selected patients to preserve functional pancreatic tissue and prevent diabetes. It should be in the armamentarium of the specialized pancreatic surgeon.

In 1991, the first laparoscopic treatment of a nonparasitic solitary hepatic cyst was published. We now report a series of eight cases and describe a standardized minimally invasive technique.Between October 1992 and December 1995, eight patients underwent laparoscopic surgical treatment for nonparasitic solitary hepatic cysts. Patients with polycystic hepatic disease were not included in our study.Cyst diameters varied from 12 to 15 cm. The mean operation time was 114 minutes, and the mean postoperative hospital stay was 8.5 days. There was no morbidity or mortality. During the mean follow-up time of 12.6 months, one asymptomatic recurrence was noted.The treatment of choice for solitary hepatic cysts that produce symptoms is laparoscopic fenestration and wide resection (deroofing) of the external part of the cyst followed by the transposition of an omental flap into the remaining cyst cavity to prevent recurrences. Laparoscopic deroofing of solitary hepatic cysts is a safe and effective procedure. This technique allows ample access for surgical treatment of solitary cysts in segments II, III, IVb, V, and VIII of the liver; however, the posterior segments, VI and VII, and segment IVa are difficult to approach laparoscopically. Hemorrhage and bile leakage can be controlled by applying a running suture to the resection margin. A cholecystectomy should be performed if gallstones are present or if the cyst is located in the right hepatic lobe adjacent to the gallbladder wall.

To correlate injury grading with computed tomography (CT) to treatment outcome.Forty-eight patients with proved blunt hepatic injuries underwent dynamic CT with contrast material before treatment. The injuries were classified with a five-point CT-based grading system. The CT injury grades and the amount of hemoperitoneum seen on CT scans were compared with the clinical and surgical findings, radiologic follow-up, and outcome.Hepatic injuries were classified as CT grade 1 in two patients, grade 2 in 15 patients, grade 3 in 21 patients, and grade 4 in 10 patients. Conservative treatment was performed in 38 patients, including 15 patients with grade 3 and 10 patients with grade 4 injuries; 10 of these patients also had major hemoperitoneum (500 mL). Conservative treatment was successful in 37 patients but was complicated in two patients by development of an arteriovenous fistula or a biloma and failed in one patient because of delayed hepatic rupture. Exploratory laparotomy was performed in 10 patients but revealed marked active hepatic bleeding in only one patient.Injury grading with CT may reflect the degree of hepatic parenchymal damage but does not indicate patients in whom complications may develop or surgery is necessary. Monitoring of conservative treatment with CT allows detection of resultant complications.

The incidence of carcinoma arising in the wall of a congenital bile duct cyst is high and there is no doubt that these lesions represent a precancerous state of the biliary tract. In almost all cases congenital bile duct cysts are related to anomalous arrangements of the pancreaticobiliary duct system which seems to play a crucial role in the development of cystic bile ducts and biliary carcinogenesis. Bile stasis together with reflux of pancreatic juice causing longstanding inflammation and activation of bile acids might be the factors in carcinogenesis of the exposed bile duct epithelium in the cystic wall. In the case of primary or secondary extrahepatic bile duct cysts, primary excision is mandatory because of the high risk to develop biliary cancer with even nowadays poor prognosis despite advantages in biliary surgery during the last years. We report a case of a young woman in which bile duct cancer was found arising in the wall of a congenital bile duct cyst. Despite radical surgery the outcome was poor proving the high malignant potential of bile duct cancer. The question of possible tumor seeding in hepatobiliary surgery is discussed as a way of inducing hepatobiliary metastatic tumors.

A new method of gastroplasty for the intrathoracic esophagus is described that requires resection of a small part of the gastric corpus only. All tributaries of the arterial arcade along the lesser curvature are preserved.The resulting gastric tube has three advantages over conventional techniques: an increase in length of the resulting gastric tube; an increase of blood flow at the tip of the gastric tube, where the anastomosis with the cervical esophagus is performed; and an increase of the gastric reservoir.Prospective clinical trial.The new technique described appears to be a safe method to substitute for the intrathoracic esophagus, although oncologic radicality and long-term follow-up results after esophagectomy for carcinoma need to be evaluated.

Bile duct papillomatosis is a rare disease. It is characterised by multicentric papillary lesions of the intra- and/or extrahepatic biliary epithelium. Because of its slow progression, its high rate of recurrence and significant risk of malignant transformation, it is an important cause of obstructive neoplastic bile duct diseases. We report one of these rare cases with the typical clinical signs and exceptional long survival time of eight years: After a history of fifteen years of recurrent epigastric pains the diagnosis of a diffuse biliary papillomatosis was made after surgery. Five years postoperatively a bile duct carcinoma has developed. After a R1-resection of the tumor, the patient was again free of complaints up to the appearances of multiple metastases two years later. He died a year later of metastasizing disease. We discuss the pathological and clinical aspects of this disease and review the literature.