Biomedical subjects

A Glättli

Publications and source records attributed to A Glättli.

At least 19 recordsLinked to original sources

PubMed2003

Laparoscopic subtotal cholecystectomy for severe cholecystitis.

BACKGROUND: In severe cholecystitis, laparoscopic cholecystectomy can be technically difficult, and is associated with an increased rate of procedure conversions and common bile duct lesions. METHODS: We investigated the safety and complications of laparoscopic subtotal cholecystectomy for severe cholecystitis in a medium- to long-term follow-up evaluation. Laparoscopic cholecystectomy was performed in 345 patients during a period of 64 months. In 46 of the patients (13.3%), a subtotal cholecystectomy was performed. The results were compared with data on laparoscopic cholecystectomy from 16,130 patients in 84 surgical institutes in Switzerland, collected prospectively by the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS). RESULTS: The median operating time was 93 min (range, 50-140) min. The overall rate of procedure conversions in acute cholecystitis was lowered significantly from 23.2% (SALTS) to 9.7%. There was no bile duct lesion, as compared with the rate of 0.8% in the SALTS data. In follow-up evaluations, fluid collections in 16 patients (35%) and residual gallstones in 6 patients (13%) were of no clinical relevance. CONCLUSIONS: Laparoscopic subtotal cholecystectomy for acute cholecystitis offers a simple and safe solution that prevents bile duct injuries and decreases the rate of conversion in anatomically difficult situations.

Adult↗

PubMed2000

[Laparoscopic transabdominal preperitoneal hernioplasty. Evaluation of complications due to transabdominal approach].

INTRODUCTION: Since the introduction of laparoscopic hernioplasty the TAPP procedure (transabdominal preperitoneal approach) has become the most widely used technique. Many surgeons have changed to the total extraperitoneal approach (TEP), because they fear the consequences of a peritoneal lesion. METHOD: We evaluated our results with TAPP in a retrospective study, with special attention to complications caused by the approach. We operated on 460 hernias in 390 patients in a period of 5 years. RESULTS: Complication rates and recurrence rates were similar to those after TEP. There was a marked learning curve with decrease of both rates during the evaluated years. There were no complications related to the transabdominal approach other than trocar hernias, the rate of which could be reduced by eliminating the learning curve and by using smaller trocar diameter. CONCLUSION: We see no reason to change from TAPP to the TEP technique.

Adult↗

PubMed2000

[Paratesticular sarcomas. Case report of leiomyosarcoma].

Paratesticular sarcomas are rare. We discuss this entity with the aid of a case report and the existing literature. The therapy of these tumors includes resection and possible adjuvant radiotherapy. Rhabdomyosarcomas are an exception, because they also show a good response to chemotherapy.

Diagnosis, Differential↗

PubMed1998

A large duplication cyst of the stomach in an adult presenting as pancreatic pseudocyst.

Intestinal duplication is a rare congenital disease. It appears throughout the gastrointestinal tract, especially in the ileum. Here we describe the rare case of a gastric duplication cyst in a 59-year-old patient. Diagnostic findings and surgical therapy are discussed. Gastric duplications in adults are extremely rare, and diagnosis is often missed. Symptoms are unspecified pain in the upper abdomen, vomiting and fever, with some patients having weight loss. Complications are rare. Chronic infections and ruptures are described. For diagnosis, CT scan with oral contrast is preferred. Endoscopy is negative in most cases. Therapy is surgery. Local excision of a small wall of gastric mucosa is sufficient in most cases, but sometimes a subtotal gastrectomy is necessary.

Cysts↗

PubMed1998

Massive gastrointestinal bleeding from colonic varices in a patient with portal hypertension.

Colonic variceal bleeding is a rarity and is most commonly due to portal hypertension. The present report describes a patient with portal hypertension due to portal vein thrombosis who, following esophageal transection and successful sclerotherapy, developed a massive lower gastrointestinal bleeding from colonic varices. The literature is reviewed, and the pathophysiology of this complication is discussed. Possible etiologies of this condition may be esophageal transection and devascularization, successful sclerotherapy, and extensive thrombosis of the portal vein resulting in obliteration of the coronary-azygous anastomotic system. In such a situation other potential sites of portosystemic anastomoses, such as the colon, may be opened up, resulting in the development of colonic varices. Indeed, the incidence of colonic varices in two series after sclerotherapy for esophageal varices was 60-100%. Of 33 candidates evaluated for liver transplantation, colonic varices were found in 1.

Adult↗

PubMed1996

[Technique and results of laparoscopic rectum resection].

The general principles of oncologic operations for colorectal cancer are the same for both open and laparoscopic surgery. Isolation of the tumor by occlusion of the intestinal lumen, early blockage of venous outflow, complete resection of the lymph node bearing mesenterium, high ligation of the artery and prevention of tumor cell dissemination during extirpation of the specimen are the most important factors. We present our technique for laparoscopic abdominoperineal resection, which fulfills the above mentioned criteria. From June 1993 to October 1994 we operated on 19 patients (median age 68 [47-91] years; male/female ratio 10/9). Laparoscopic abdominoperineal resection of the rectum was palliative in 3 patients and curative in 16. Tumors were located 3 (1-8) cm from the anal verge. In 3 patients the operation was converted to open surgery. Intraoperative complications were encountered in 3 patients. Median operation time was 300 (200-400) minutes and postoperative morbidity 8/19 (42%) leading to reoperation in one patient. 30-day mortality was nil. Three patients died 5, 8, and 14 months postoperatively due to metastatic disease (all 3 after initial palliation). One patient had local recurrence and liver metastasis and died 14 months after operation. Another patient died from liver metastases. In one patient a single liver metastasis was successfully removed. 14 patients were tumor-free after a median follow-up of 10 (3-14) months. There was no implantation metastasis on a trocar site. Laparoscopic abdominoperineal resection of the rectum is feasible and the results are comparable with those of open surgery. Local recurrence rate and incidence of liver metastases are comparable with open surgery after this short follow-up. However, 5-year survival is needed to judge the oncological radicality of laparoscopic abdominoperineal resection of the rectum.

Adenocarcinoma↗

PubMed1995

Injury to the diaphragm and its repair during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has now become the "gold standard" for the treatment of gallstone disease. Parallel with the conversion from the open to laparoscopic technique, some complications peculiar to the laparoscopic approach have been experienced. Such a technique-related complication, resulting in an injury to the diaphragm and its repair during laparoscopic cholecystectomy is presented.

Acute Disease↗

PubMed1995

Is there still a place for abdominoperineal resection of the rectum?

During the past two decades, low anterior resection (LAR) with colo-rectal or colo-anal anastomosis has replaced abdominoperineal resection (APR) as the primary surgical therapy for rectal cancer. Several studies, although not prospectively randomized, have shown that the outcome after LAR with deep anastomosis and APR is comparable concerning mortality, local recurrence rate and survival. Adequate clearance of the tumour, and not the surgical procedure performed, is the determinant factor influencing the outcome. Whereas most tumours in the upper third and mid-rectum are amenable to a sphincter-saving procedure (SSP), the lower third of the rectum is of debate in this respect. Small tumours (T1) in the lower third can be treated by peranal local excision. Low grade tumours with a T2 or T3 stage located above 3 cm from the dentate line are treated by SSP. There is still a place for for advanced tumours (T3 and T4) below 5 cm from the anal verge, in case of deficiency of the anal sphincter, and when the sphincter complex is infiltrated by the tumour. Preoperative staging measures are essential for patients selection in relation to height of the tumour above the anal canal, depth of tumour invasion into the rectal wall, and presence or absence of regional lymph node metastases. Biology of rectal cancer and its implication on surgery, preoperative staging of rectal cancer, technique and results of the main three surgical options, and the advent of laparoscopy are discussed in this article.

Abdomen↗

PubMed1995

[Congenital cystic duplication of the stomach--a rare surgical disease].

Duplication of the stomach is a rare congenital disease of the childhood. We report the exceptional manifestation in two adults. The clinical presentation and developmental theory is discussed by reviewing the literature. Today the therapy of choice is resection of the duplication with removal of the adjacent wall of the stomach.

Adult↗

PubMed1995

Subcutaneous periumbilical metastasis of a gallbladder carcinoma after laparoscopic cholecystectomy.

The frequency of gallbladder carcinoma is 1.2 to 7.4% of all cholecystectomy specimens. In open cholecystectomy for gallstone disease, undetected gallbladder carcinoma is found postoperatively in the histological examination in 0.3%. Tumor cells of these clinically inapparent gallbladder carcinomas can be implanted at the trocar sites during laparoscopic cholecystectomies. We report a case with subcutaneous tumor seeding at the navel trocar insertion site in a 65-year-old woman.

Abdominal Muscles↗

PubMed1994

[Laparoscopic cholecystectomy in morbid obesity].

In the early days of laparoscopic cholecystectomy (LC) morbid obesity was considered a relative contraindication for this procedure. With increased experience the procedure has been used in obese patients too. To evaluate the influence of morbid obesity on feasibility and outcome of LC, we performed a prospective study in 136 patients in whom LC was attempted between January 1991 and January 1992. Conversion to open cholecystectomy was necessary in 26 cases (19%). The remaining patients were divided into two groups. Group 1 consisted of 92 normal or slightly obese individuals, whereas 18 morbidly obese patients were included in group 2. Intraoperative problems (42% vs 61%) and postoperative morbidity (2% vs 11%) were less frequent in group 1, although not statistically significant. There was no difference in operating time (median for both groups: 110 minutes) and length of hospital stay (4 days). The incidence of late complications (3% vs 6%) was similar. We conclude that LC in morbidly obese patients, as in open surgery, is technically more demanding than in normal individuals. The operative risk was elevated (p < 0.05) as evidenced by a tendency to higher intra- and postoperative complication rates. Cholecystolithiasis in morbidly obese patients is a good indication for LC in the hands of well trained laparoscopic surgeons who are ready to convert to open surgery if problems arise.

Adult↗

PubMed1994

[Laparoscopic cholecystectomy: current status].

Since its introduction a few years ago, laparoscopic cholecystectomy has become today the standard treatment of gallbladder stones. Compared to open surgery it involves little change in the preoperative investigations. There has been, especially in the beginning of the learning curve, a demand for preoperative visualization of the bile duct anatomy and for exclusion of intraductal stones. Thus the incidence of preoperative ERCP has risen with the development of laparoscopic cholecystectomy. For the advanced laparoscopic surgeon, the indications for laparoscopic cholecystectomy are the same as for open surgery. The benefits of laparoscopy for the patient are obvious and the results are favourable. Bile duct injury is a very severe complication and, at the beginning of the learning curve, the incidence has been somewhat higher than in open surgery. Therefore, proper training in laparoscopic surgery and quality control are necessary. Many reports on advanced laparoscopic procedures have already been published, but only the future will show the limits of this technique.

Bile Ducts↗

PubMed1994

[Second look laparoscopy after mesenteric infarct].

Second-look laparotomy is not always routinely performed after mesenteric infarction. Such operations are often not performed because of the high operative risk in aged patients and those with cardiovascular disease. We developed a minimally invasive technique for second-look laparoscopy with the aim of decreasing the operative morbidity. With the patient under general anaesthesia, the old incision is opened at the umbilicus. The running suture in the abdominal wall is lifted with a clamp and the incision line is gently reopened. A trocar with a blunt tip designed for open laparoscopy is then inserted and fixed. Following insufflation of CO2 through the trocar it is possible to explore the entire small bowel and colon. We operated on five patients after bowel resection performed for mesenteric infarction. Second-look laparoscopy was diagnostic in all but one, in whom laparoscopy failed due to massive small bowel dilatation. The technique described here is very promising and deserves further evaluation.

Aged↗

PubMed1994

Cholecystocholangiography vs cystic duct cholangiography during laparoscopic cholecystectomy. A prospective controlled trial.

Intraoperative cholangiography performed during laparoscopic cholecystectomy provides an exact picture of the biliary anatomy. It may prevent iatrogenic bile duct injury and detect unsuspected common duct stones. Laparoscopic cannulation of the cystic duct can be difficult and time-consuming. We therefore evaluated the simpler technique of cholecystocholangiography by direct puncture and filling of the gallbladder with contrast medium. This technique was compared with cystic duct cholangiography in a prospective controlled trial of 69 patients. Cystic duct cholangiography (n = 38) showed significantly better results than cholecystocholangiography (n = 31) with optimal visualization of the biliary tree in 29 cases (76%) and seven cases (22%), respectively. The failure rate was 8% and 52%, respectively. Delineation of the cystic duct junction is important in order to prevent bile duct injury. The anatomy in this region was clearly delineated in 34 cases (89.5%) using cystic duct cholangiography but only in 11 cases (35.5%) with cholecystocholangiography. Cystic duct cholangiography revealed unsuspected common duct stones in three cases; however, choledocholithiasis was missed by cholecystocholangiography in at least two patients. Cystic duct cholangiography is clearly the optimal technique. In situations of unclear anatomy in which safe dissection of the cystic duct is not possible, cholecystocholangiography remains a useful alternative.

Adult↗

PubMed1994

Blunt splenic trauma in adults: can CT findings be used to determine the need for surgery?

OBJECTIVE: The role of CT grading of blunt splenic injuries is still controversial. We studied the CT scans of adult patients with proved blunt splenic injuries to determine if the findings accurately reflect the extent of the injury. We were specifically interested in establishing if CT findings can be used to determine whether patients require surgery or can be managed conservatively. MATERIALS AND METHODS: The CT scans of 45 patients with blunt splenic injuries were analyzed retrospectively, and the CT findings were correlated with the need for surgery. We used (1) a CT scale (I-V) for splenic parenchymal injuries that also allowed a comparison with the surgical findings in patients who underwent laparotomy, and (2) a CT-based score (1-6) that referred to both the extent of parenchymal injuries and the degree of hemoperitoneum. Early laparotomy was done in nine patients. Conservative treatment was attempted in 36 patients and was successful in 31; five patients needed delayed laparotomy after attempted conservative treatment. RESULTS: According to the CT scale (I-V), 25 patients had injuries of grade I or II; 20 patients were successfully treated conservatively, whereas five patients needed delayed surgery. Nineteen patients had injuries of grade III, IV, or V; eight patients underwent early laparotomy, and 11 patients were successfully treated conservatively. CT findings were false-negative in one patient who underwent early surgery for diaphragmatic rupture. A comparison of the CT findings with the intraoperative findings according to the CT scale (I-V) revealed identical parenchymal injury grades in four cases, whereas the injuries were underestimated on CT scans in four patients and overestimated on CT scans in six patients. The CT-based score (1-6) was applied to 41 patients; four patients who had peritoneal lavage before CT were excluded. Twelve patients had scores below 2.5; 10 patients were successfully treated conservatively, and two patients needed delayed surgery. Twenty-nine patients had scores of 2.5 or higher; six patients underwent early laparotomy, 20 patients were successfully treated conservatively, and three patients needed delayed surgery. Patients who required delayed surgery had a mean score of 3.0 (SD, +/- 1.0), which was similar to those who did not require surgery (3.1 +/- 1.5; p = .45). CONCLUSION: Our results show that CT findings cannot be used to determine reliably which patients require surgery and which patients can be treated conservatively. Even patients with splenic parenchymal injuries of CT grade III, IV, and V and with CT-based scores of 2.5 or higher can be successfully treated conservatively if the clinical situation is appropriate, whereas delayed splenic rupture can still develop in patients with low CT grades or scores. The choice between operative and nonoperative management of splenic trauma should be mainly based on clinical findings rather than CT findings.

Adult↗

PubMed1993

Unresectable malignant biliary obstruction: treatment by self-expandable biliary endoprostheses.

The primary goal in the treatment of malignant obstruction is the relief of jaundice. Although operative biliary bypass is a reliable method of palliation, nonoperative palliation may be desirable in selected patients. We report our experience with forty-eight self expandable metallic biliary endoprostheses (Wallstent) percutaneously placed in 35 patients with irresectable malignant biliary obstruction. In twelve patients more than one stent was necessary to bridge the entire length of the biliary stenosis. The obstruction was due to primary tumors in 14 and to lymph node metastases in 12. In nine patients transanastomotic stents were placed after previous bilioenteric anastomosis because of malignant obstruction. Complications occurred in 11 patients (31.4%), and five patients died within 30 days of stent placement (14.3%). The mean stent patency to date of patients discharged is 6.1 months, and the mean survival 7.2 months. Follow up data is available for 29 patients, and excellent palliation was achieved for more than 75% of the survival time in 22 (76%). Seven patients have had documented stent occlusion requiring further intervention (24%). In this selected group of patients, the results of percutaneous self-expandable stents are encouraging. However, our data does not support the initial reports of self-expandable endoprostheses that suggest an improved result compared to conventional plastic stents. A randomized study using either expandable stents as compared to operative biliary enteric bypass is necessary.

Adenoma, Bile Duct↗

PubMed1993

[Cholecysto-cholangiography as an alternative to cystic duct cholangiography in laparoscopic cholecystectomy].

Intraoperative cholangiography may be an important adjunct to laparoscopic cholecystectomy in order to prevent bile duct lesions. Laparoscopic cannulation of the cystic duct can be very difficult and time consuming. We therefore developed a simple technique of cholecystocholangiography. The gallbladder is punctured and filled with contrast medium after having localised the cystic duct and put a metal clip as a landmark. The study included 52 patients having either cholecystocholangiography or cystic duct cholangiography. In 13 out of 26 patients (50%) cholecystocholangiography failed because of obstruction of the cystic duct. The cholangiograms showed complete filling of the bile ducts in 5 (19%) and incomplete visualisation in 8 cases (31%). Cystic duct cholangiography showed significantly better results with good delineation of the biliary tree in 19 cases (73%). Five cholangiograms were suboptimal (19%) and only 2 studies failed (8%). The relation between cystic duct and common bile duct was clearly visible in 24 cases (92%) with cystic duct cholangiography compared with 13 cases (50%) with cholecystocholangiography. Cystic duct cholangiography has better success rates in delineating biliary anatomy in order to prevent bile duct injury. Cholecystocholangiography is a good alternative in cases where the cystic duct cannot be initially visualized.

Adult↗

PubMed1993

[Biliary pancreatitis--a good indication for laparoscopic cholecystectomy].

Recently the indication for laparoscopic cholecystectomy has been enlarged to include biliary pancreatitis. While a majority of reports recommend early open cholecystectomy for biliary pancreatitis the use of laparoscopic cholecystectomy in this disease has not yet been discussed. We retrospectively reviewed 52 patients with biliary pancreatitis being admitted to our ward in the last five years. Cholecystectomy was performed in 48 patients. Ten had undergone laparoscopic cholecystectomy. Postoperative complications occurred in 8 of the 48 patients (16.6%). Four patients (8.3%) died due to necrotizing pancreatitis or rupture of pseudocysts. We found a correlation between morbidity and mortality and the prognostic score as well as the presence of pseudocysts. We conclude that biliary pancreatitis is a good indication for laparoscopic cholecystectomy in patients with a low prognostic score. The presence of pseudocysts in our view is no contraindication for laparoscopy. Although it may increase postoperative morbidity. Choledocholithiasis has to be ruled out either by preoperative ERCP or during laparoscopy with intraoperative cholangiography.

Acute Disease↗