Thank you for visiting my website. I am a Professor of Visceral Surgery specializing in operations on the internal organs, in particular the gastrointestinal tract, lungs and thyroid gland.
My patients benefit from my decades of experience in this field, with the range extending from routine operations (hernias, etc.) to very complex procedures on patients with tumours. My core competence is operations on the colon – particularly surgery for malignant tumours – and operations to reduce obesity, such as stomach bypass surgery.
Wherever possible and advisable, we perform the operations using minimally invasive video-optical techniques. Our practice is part of Klinik Hirslanden in Zurich and I am also based in Spital Männedorf, guaranteeing optimum communication between the individual disciplines and the availability of doctors in all specialities – a particularly important factor in the comprehensive treatment of cancer patients.
For more information about my training and academic career, range of surgical procedures, interdisciplinary network and the locations where we practise, please take a look at the rest of my website.
I aim to provide the highest level of specialist expertise, detailed and understandable advice, and compassionate and friendly treatment and care.
To make an appointment at my practice in Klinik Hirslanden,
please contact my secretary’s office:
Prof. Dr. med. Rolf B. Schlumpf
Partner in the group practice
Klinik Hirslanden
Witellikerstrasse 40
(Enzenbühltrakt entrance)
8032 Zürich
Switzerland
T +41 44 387 31 50
F +41 44 387 37 01
To make an appointment at my practice in Spital Männedorf,
please contact my secretary’s office:
Prof. Dr. med. Rolf Schlumpf
Senior consultant for visceral surgery
Chirurgische Klinik
Spital Männedorf
Asylstrasse 10
Postfach
8708 Männedorf
Switzerland
T +41 44 922 25 11
F +41 44 922 25 05
Professor Schlumpf’s practice is located in Klinik Hirslanden, which is on the right side of Lake Zurich between Zurich and Zollikon. With its panoramic view over the lake and mountains, the peaceful location on the Zürichberg hill provides the perfect atmosphere for rest and recuperation.
Tram no. 11 from Zurich main station or Zurich Stadelhofen station (towards Rehalp) to the Balgrist stop.
Forchbahn suburban railway S 18 from Stadelhofen station (towards Forch/Esslingen) to the Balgrist stop.
An online timetable is available at www.sbb.ch/en/timetable.html.
Klinik Hirslanden is a five minute walk from the Balgrist stop, at Witellikerstrasse 40.
The practice is located in wing E, Enzenbühltrakt entrance.
Take the S-Bahn to the main railway station, then tram no. 11 (towards Rehalp) to the Balgrist stop.
Klinik Hirslanden is around 40 minutes from the airport by taxi.
Parking spaces are available for visitors (for a charge) in the underground car park. The opening hours are from 6 am to 9 pm daily. Please note that there is very little parking available (blue zone) near the Klinik.
Klinik Hirslanden is a modern private hospital in Zurich and is part of Hirslanden, Switzerland’s leading private hospital group. The modern infrastructure and medical expertise of our doctors and other staff have been central to our approach and philosophy for many years – enabling you to feel completely at ease in our care.
Klinik Hirslanden’s quality management was commended by the Recognised for Excellence scheme (R4E****) on 27 March 2009. External assessors from the European Foundation for Quality Management gave the hospital 400 to 450 points and thus awarded it a Recognised for Excellence four-star rating – making Klinik Hirslanden one of the leading providers in the healthcare sector.
Spital Männedorf on the banks of Lake Zurich – personal and competent. With a staff of just under 800, the clinic treats and cares for around 36,000 people a year. Thanks to its high standards of nursing care and medical expertise combined with a modern infrastructure, Spital Männedorf can offer treatment that is tailored to every patient’s individual needs.
The spectrum of services provided ranges from basic medical care in emergencies to a variety of extended basic health care packages. The three clinics – Medicine, Surgery and Gynaecology & Obstetrics – are supplemented by the Institute of Anaesthesia & Intensive Care and the Institute of Radiology. Spital Männedorf also offers an intensive care unit and an ambulance service.
Spital Männedorf places particular focus on holistic care and a personal atmosphere, with the clinic aiming to provide the highest quality treatment for every patient. Quality measurement is well-established here: for many years, Spital Männedorf has been participating in specific measurement programmes in order to monitor and improve its performance quality. And it meets the high standards of HQuality® , a quality seal awarded to clinics that offer their patients with supplementary insurance cover exceptional standards of care and high-end hotel services.
Spital Männedorf
Surgical Clinic
Asylstrasse 10
8708 Männedorf
Switzerland
T +41 44 922 25 11
F +41 44 922 25 05
Prof. Dr. med. Rolf B. Schlumpf
Klinik Hirslanden
Witellikerstrasse 40
8032 Zürich
Switzerland
T +41 44 387 30 50
F +41 44 387 37 01
E-Mail
Klinik Hirslanden
Spital Männedorf
prof-rolf-schlumpf.ch regularly reviews and updates the information on its website. In spite of all diligence, however, the data may have changed in the meantime.
Therefore, we cannot guarantee or assume liability for the timeliness, accuracy and completeness of the information provided on this website.
The same applies to all other websites referred to via hyperlinks. prof-rolf-schlumpf.ch is not responsible for the content of websites that can be accessed through such links.
Furthermore, prof-rolf-schlumpf.ch reserves the right to make changes or additions to the information provided on this website.
The content and structure of the prof-rolf-schlumpf.ch website are protected by copyright. No information or data on this site, especially texts, text passages or images, may be reproduced without the prior permission of prof-rolf-schlumpf.ch.
Fundamentally, the only personal data that we collect on you is the information that you provide voluntarily. This may occur, for example, when you submit personal data in a request to us. The personal data that you voluntarily submit to us will be stored and processed only in Switzerland.
The personal data provided by you and collected by us in connection with your usage of the prof-rolf-schlumpf.ch website will be used only for the purpose of processing your requests or providing the requested services. Your express consent is required for any use of your personal data above and beyond this purpose. The same applies to the disclosure or transmission of your data to third parties. You may revoke any consent granted previously at any time with effect for the future.
Please note that e-mail communication takes place via the open Internet. The confidentiality and integrity of information transmitted cannot therefore be completely guaranteed. It is your responsibility to ensure the confidentiality and integrity of your messages. This also applies to messages that you send directly via our services (e.g. in the "Contact" section).
Treatment appointments etc. are only binding for us if we send you an appointment confirmation. If you need to know the exact time of receipt, we recommend that you request a read confirmation.
This website uses Google Analytics, a web analytics service provided by Google, Inc. (“Google”). Google Analytics uses “cookies”, which are text files placed on your computer, to help the website analyse how users use the site. The information generated by the cookie about your use of the website (including your IP address) will be transmitted to and stored by Google on servers in the United States. However, if IP anonymization is activated on this website, Google will first truncate your IP address within Member States of the European Union or in other states that are parties to the Agreement on the European Economic Area. Only in exceptional cases will the full IP address be sent to and shortened by Google servers in the USA. On behalf of the operator of this website, Google will use this information for the purpose of evaluating your use of the website, compiling reports on website activity and providing other services relating to website activity and Internet usage to the website operator. Google will not associate your IP address with any other data held by Google. You may refuse the use of cookies by selecting the appropriate settings on your browser. However, please note that if you do this, you may not be able to use the full functionality of this website. Furthermore, you can prevent Google’s collection and use of data (cookies and IP address) by downloading and installing the browser plug-in available under: http://tools.google.com/dlpage/gaoptout.
The colon receives indigestible food components from the small intestine and removes water and any remaining nutrients/salts (electrolytes) from this undigested matter. The rectum is the final section of the digestive system and is where solid waste is temporarily stored until the next bowel movement; it opens into the anal canal (anus), the lower opening of the digestive tract.
Surgical removal of parts of the colon or rectum is needed if a patient has a tumour (colorectal cancer) or inflammatory bowel disease (diverticulitis, ulcerative colitis and Crohn’s disease). If you have a malignant tumour, an operation is always part of the treatment. The situation of patients suffering from a malignant colorectal tumour is discussed at our clinic in order to plan treatment during an interdisciplinary Tumour Board Meeting – which takes place weekly in competence centres for tumour treatment – in the presence of all necessary specialists. The next treatment steps are subsequently proposed at these meetings. A surgeon, oncologist, radiotherapist, gastroenterologist, pathologist, nuclear medicine specialist and possibly other specialists are present.
If you have inflammatory bowel disease, an operation is frequently necessary but is generally only performed after a period of medical treatment.
If you notice blood in your stools, this may indicate a tumour in your colon. Changes to your normal bowel habits – such as constipation or frequent and sometimes loose bowel movements – may also be a sign of bowel cancer. In rare cases, an intestinal obstruction may result in a medical emergency. Diverticular disease, on the other hand, is relatively common; typical symptoms include (recurrent) pain in the lower left part of the abdomen and a high temperature. Diverticula are irreversible small pouches that protrude from the wall of the colon. They are very common in people over 50 and tend to cause recurrent inflammation. If you notice any of the symptoms mentioned, we recommend making an appointment to see your GP.
A colonoscopy (examination of the colon) is a key test in diagnosing colorectal tumours; it entails a flexible tube with a miniature video camera being inserted through the anus into the bowel. A tissue sample can also be taken during this examination. In order to determine the stage of the tumour, a CT (computerized tomography) scan and possibly also an MRI (magnetic resonance imaging) or ultrasound scan are necessary as well. For patients with inflammatory bowel diseases, particularly diverticulitis, CT scans are normally used for the initial diagnosis. A colonoscopy is generally only performed after the inflammation has subsided. If necessary and depending on the stage of the investigation, we would be happy to arrange these tests for you.
As soon as a malignant colorectal tumour has been diagnosed, we discuss the situation at the interdisciplinary Tumour Board Meeting. If patients have a tumour in their colon, surgery is generally the first therapeutic step. If patients have a malignant rectal tumour, it is often – depending on the stage of the tumour – first treated with radiotherapy (radiation) and chemotherapy (treatment with medication) prior to surgery.
When rectal tumours are operated on, the location of the tumour (distance from the anal sphincter) means that a decision needs to be made about whether to create a permanent artificial anus, which is rarely done nowadays. As soon as the treatment plan has been drawn up, I see the patients in my practice and discuss their diagnosis and therapy with them in detail as well as the next steps. I always set aside plenty of time for this appointment to ensure that we can discuss all the questions that patients may have. In the case of inflammatory bowel diseases, there is generally more time available to plan an operation. An exception to this is inflammatory intestinal perforation, which requires emergency surgery.
Abdominal surgery, normally laparoscopic
Transanal surgery
A polyp is a growth in the intestinal mucosa which is normally benign and does not cause any problems. However, polyps may develop into cancer over time. They can be detected and removed during colonoscopy screening (preventative examination of the colon, recommended from the age of 50).
If you are having surgery on your colon or rectum, you will need to be admitted to the clinic the day before your operation. I will of course see you personally after you have been admitted and we will discuss any questions that you may still have. Depending on your general state of health and documentation, you will be examined by an internal medicine specialist when you are admitted. A blood test is always necessary and you may also need to have an ECG and chest X-ray. You will only need to have a bowel washout if you are undergoing rectal surgery. The evening before your operation you may have a light meal (if you are having rectal surgery, you will only be allowed liquids). You will then meet your anaesthetist, who will discuss the anaesthetic with you. A general anaesthetic is almost always required for colorectal procedures.
Colorectal surgery is one of my areas of specialization and a field in which I have a great deal of expertise and experience. Wherever possible, I perform this surgery using minimally invasive techniques (“keyhole surgery”). This method, also known as laparoscopy, involves inserting optical and surgical instruments into your abdominal cavity through small cuts in your abdominal wall. As a result, my patients avoid having to suffer a large incision, pain and unattractive scarring.
The affected sections of the colon or rectum are removed along with a small segment of normal bowel on either side as a safety margin. As part of this procedure, the vessels leading to this section of the intestine must be identified, sealed off and severed. In the case of tumours, it is particularly important to also remove the associated lymph nodes since they will subsequently need to be examined under the microscope for cancer cells (lymph node metastases). In most cases, a segment of bowel measuring approximately 30 cm is removed. The remaining ends of bowel must then be joined together, generally using a surgical stapler (the sections are connected using small titanium staples). Depending on the type of procedure, the operation lasts between 90 minutes and around four hours. I perform the procedure on my patients personally, from start to finish.
In experienced hands these operations can be performed very safely nowadays; post-operative bleeding, for example, is extremely rare. Nevertheless, other complications may occasionally occur. The most serious complication is leaking of the new join in the bowel (anastomotic insufficiency). Depending on the type of procedure, the risk is around 3% and affects the first five days after surgery. Infection of the wound, a bladder infection and more rarely deep vein thrombosis or other complications may sometimes also occur. I always check on my patients personally on my daily ward rounds and look after them from the time that they are admitted until they are discharged.
Long-term problems are rare after most procedures and the patient’s quality of life is not usually affected.
After the operation you will usually spend a night in the recovery room or in intensive care. We place great emphasis on effective pain relief. You can drink a few hours after the operation. On the first day after surgery, you will be able to sit in an armchair and walk short distances. Depending on the type of procedure, you will be able to eat liquid or soft foods on the first day, mashed potatoes and similar foods on the second day, and you will usually be able to eat a normal light diet on the third day. Since the incisions in your skin are covered with small transparent films, you do not need to have the dressing changed in the first few days; you will be able to shower as soon as the intravenous drip (supplying fluids, painkillers, etc.) has been removed (second or third day after the operation). We use an intracutaneous suturing technique (just below the surface of the skin), which provides the best cosmetic results and means that no stitches need to be removed. As after any operation, an antithrombotic drug will be injected into your leg subcutaneously every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. Depending on the type of procedure, patients need to stay in the clinic for 5 to 10 days after bowel surgery.
Most patients are independent, have no need of nursing care and no longer require much, if any, pain relief when they are discharged. Depending on the type of procedure, your bowel movements may be irregular for several weeks (increased stool frequency), but will return to normal in the long term. Even if your general health is very good, we recommend that you allow for a recovery period of at least two weeks after leaving the clinic and do not return to work during this time. You should avoid sport for four weeks after the operation.
When patients undergo surgery for a malignant tumour, the results of the pathological examination of the bowel segment removed are discussed at a meeting with the other tumour specialists. If the tumour has not spread, additional treatment is not usually required; however, long-term follow-up involving regular medical check-ups will be needed. If the tumour has invaded the lymph nodes that were removed as part of the procedure (lymph node metastases), we recommend – in line with international standards – additional chemotherapy (drug treatment). This can reduce the risk of the tumour returning, which improves the prognosis.
We are now able to cure many patients with malignant bowel tumours. Nevertheless, even the best treatment cannot prevent a certain risk of recurrence – depending on the stage of the tumour. The prognosis is worse if lymph node or liver metastases are present, but even then the situation is not without hope and should certainly be discussed with a specialist. I will of course continue to be available to you after your operation and meet every patient to discuss in detail the next steps in his or her individual case.
Patients who undergo surgery for diverticular disease are healthy after they have recovered from the procedure; recurrence of diverticulitis is very rare.
Weight loss surgery, also known as bariatric surgery, refers to surgical procedures that are performed to treat morbid obesity. The aim is to help patients who cannot achieve adequate weight loss using conventional methods. An operation of this kind is the most invasive but at the same time the most successful treatment option. Reducing a patient’s weight significantly improves their quality of life and general state of health since many obesity-related illnesses can be improved or even cured.
Changes in our eating habits and diet and the lack of exercise in today’s society are among the factors that have led to morbid obesity becoming increasingly common. Those affected suffer both personally and professionally – in their relationships and career – as well as physically due to related illnesses such as high blood pressure, diabetes, and wear and tear on joints. Once an individual has reached a certain level of obesity (body mass index over 35 kg/m2), dieting alone is generally unsuccessful and it is worth considering surgical treatment. The most common bariatric procedures are gastric bypass and sleeve gastrectomy. These treatment options are covered by health insurance. Body mass index (BMI) is calculated using the following formula: body weight in kilograms divided by height in metres squared.
For example: weight 110 kg, height 170 cm; 110 divided by 1.7 x 1.7 (2.89) = 38.0 kg/m2.
I have been helping patients with morbid obesity since 1995, when I was the first surgeon in Switzerland to perform laparoscopic gastric band surgery. Tremendous advances have since been made in bariatric surgery and, on the basis of many years of experience, we are now able to offer you a highly competent interdisciplinary treatment approach. Please contact us to make an appointment for an initial consultation.
Individuals affected have frequently struggled with their weight since childhood or puberty. It is not uncommon for additional significant weight gain to occur after a pregnancy or a psychologically traumatic event. Numerous attempts at dieting and exercise and even medication result in temporary weight loss but are then followed by renewed weight gain, with the individual weighing more than before they started (yo-yo effect). Over time, those affected frequently develop high blood pressure and subsequently type 2 diabetes. This increases the risk of related health problems such as heart attacks, strokes, arteriosclerosis and many other diseases. Joint wear and tear, varicose veins, urinary incontinence and sleep apnoea syndrome may also occur alongside social consequences such as isolation, sexual abstinence and difficulties at work. Having a BMI of more than 35 kg/m2 is a clear warning sign. In today’s society, those affected have approximately only a 7% chance of achieving sustained and effective weight loss through dieting alone. If you have a BMI of over 35 kg/m2, it is time to consult a doctor who specializes in these issues. We would be delighted to discuss the matter with you further.
If we determine at your appointment that you need weight loss surgery, I will refer you to our internal specialists (metabolic medicine/endocrinology) who will carefully assess your needs. This will involve at least two outpatient appointments at which you will have a full medical examination, including a blood test, an ECG while using an exercise bike, a gastroscopy and an ultrasound scan. You will also receive further information about the situation after the operation and initial instructions from a dietician.
As soon as the investigations have been completed, I will discuss the situation with the internal specialist and anaesthetist. Based on the results of the examinations, we will draw up a proposal about which operation would be most suitable for you. You will then have a further appointment at which we will make a final decision about the type of procedure, the date on which you will be admitted and the date of your operation.
For most patients, I would recommend gastric bypass surgery – the gold standard of bariatric procedures. Like other centres worldwide, we have many years of experience with gastric bypass operations. This ensures that the treatment is extremely safe and that we are able to give a very precise prognosis of the long-term outcome.
Sleeve gastrectomy (gastric sleeve surgery), on the other hand, is a procedure that has only been performed on a wide scale for the past few years. The operation is relatively simple and the results in the first two years are very good. The long-term outcome is not always as satisfactory, however, since it is not uncommon for patients to regain weight. We recommend this type of procedure in two situations: first, for selected patients with a BMI of 65 kg/m2 or above (e.g. weight = 220 kg, height = 180 cm, BMI = 67.9 kg/m2). It can be technically very difficult to perform gastric bypass surgery on patients of this weight. Performing the simpler sleeve gastrectomy procedure enables these patients to lose 70 to 80 kg over one to two years, for example; we can then convert the sleeve to a bypass with minimal risk, guaranteeing a good long-term outcome. Second, we also perform sleeve gastrectomy on patients with a BMI at the lower end of the range, in other words individuals who have a BMI between 35 and 37 kg/m2. According to the information currently available, satisfactory long-term results can be achieved for patients in this range.
We no longer offer gastric band surgery. I myself performed the first laparoscopic gastric banding in Switzerland at University Hospital Zurich in 1995. This procedure is very simple and early complications are rare. However, the quality of life and long-term results are so poor that we stopped performing the operation in 2002.
Depending on your general state of health and any associated illnesses that you may have, you will either be admitted to the clinic the day before the procedure or just a few hours before the operation. Apart from a blood test, no other examinations are generally required since they will already have been performed beforehand. After you have been admitted, you will be seen by the anaesthetist who will discuss your anaesthesia care with you. A general anaesthetic is always required for this type of procedure. You may have a light meal the evening before your operation and you will be able to drink up to six hours before the procedure.
Weight loss surgery is one of my areas of expertise; I have invested a great deal of time in developing this speciality and have extensive experience in the field. It goes without saying that I perform the procedure on my patients myself, from start to finish. We can almost always perform these operations laparoscopically (keyhole surgery). In this method, also known as abdominal endoscopy, optical and surgical instruments are inserted into the abdominal cavity through small incisions in the abdominal wall. This saves you from having to undergo a large incision, pain and unattractive scarring. You will have virtually no pain after surgery and will soon be able to stand up and walk around, minimizing the risk of thrombosis or a pulmonary embolism, for example. A general anaesthetic is always required for these procedures.
In a first step the surgeon divides the stomach horizontally near the top, just below the stomach entrance. This creates a stomach in the size of an espresso cup, known as a pouch, which significantly restricts the amount of food that can be eaten. The rest of the stomach (known as the blind stomach) is closed at the edge of the cut using small staples and remains where it is, but is no longer part of the digestive process.
In a second step a section of small intestine measuring around 1.5 metres in length (proximal gastric bypass) is pulled up to the small stomach and connected to it. This surgical connection between two hollow organs, or between blood vessels, is called an anastomosis. Food in the stomach then passes directly into this shortened section of small intestine. However, it cannot be digested there due to the lack of digestive enzymes from the pancreas and gall bladder (“bypass effect”).
In a third step the section of intestine that transports food is therefore connected to the segment of intestine coming from the duodenum, which receives enzymes and bile. Enzymes are biochemically active proteins that are released from the pancreas into the duodenum. They are capable of breaking down food into fats, carbohydrates and proteins so that it can be digested. Food can now be digested downstream of this new connection, but only until the small intestine joins the large intestine and ends (food cannot be digested in the large intestine).
The section of small intestine available for digestion after the procedure is 1.2 to 2.0 metres, which is of course too short (it normally measures 3.5 to 4.0 metres); as a result, undigested food also enters the large intestine and leaves the body in the stools. This leads to fewer calories being absorbed.
Bypass surgery therefore works in two ways: first, by significantly limiting the quantity of food that can be consumed (restriction) and second, by preventing food from being completely digested (malabsorption). The procedure takes between 90 minutes and two hours.
This operation involves removing a large part of the stomach so that only a tube-shaped section remains. This significantly reduces the volume of food that can be eaten (restriction). In addition, mechanisms that have not yet been fully researched (changes in the secretion of transmitter substances) lead to the patient feeling full more quickly. The procedure takes between 60 and 90 minutes.
Both types of procedure are associated with a risk of thrombosis and pulmonary embolism (less than 1%), wound infections and incisional hernias (also rare). In the long term, the significant amount of weight that patients lose may leave them with unattractive excess skin on their belly, upper arms and thighs. Understandably, most patients then wish to have corrective surgery (after two years at the earliest), but must be aware that such measures (plastic surgery) are not generally covered by health insurance.
One of the most serious early complications (within the first five days after surgery) is leakage from the join in the stomach or intestine (anastomotic leak). As a result, contents of the stomach or intestine can enter the abdominal cavity and cause an infection, requiring an emergency operation. This complication occurs in fewer than 1 to 2% of procedures.
Rare long-term complications include shrinkage of the scar tissue at the connection between the stomach and small intestine (anastomosis stricture) or the formation of a benign ulcer (anastomotic ulcer) at this site.
Some patients may suffer from what is known as dumping syndrome: when food passes from the stomach to the small intestine too quickly, fluctuations in the blood sugar level can cause dizziness, shakiness and palpitations. This can usually be treated by making dietary changes (not drinking at meal times, for example). In rare cases – sometimes even several years after the procedure – an internal hernia may occur: loops of small intestine can protrude through surgically created defects in the mesentery (the suspension structure of the intestine) and may become trapped; this requires emergency surgery. A lack of vitamins and minerals, and occasionally of proteins, is always a possibility in the long term due to malabsorption (poor digestion of food). To prevent this occurring, regular medical check-ups and lifelong supplementation with at least one vitamin product are necessary.
Here too, leakage from the staple line in the gastric sleeve may occur soon after surgery; the risk is approximately 1%. A second operation to correct the leak is usually required immediately. In very rare cases, there may be post-operative bleeding into either the abdominal cavity or the gastric sleeve. In the long term, a not insignificant number of patients complain about acid reflux, which can usually be controlled by medication. A certain risk of relapse is also associated with this type of operation. This means that after around two years, the patient begins to regain weight (frequently as a result of the gastric sleeve stretching). Surgery is then generally recommended to convert the sleeve to a bypass.
Since these operations are almost always performed laparoscopically, pain is kept at a very manageable level and can be well controlled by medication. You will not be allowed to eat or drink the first night after the operation. You will be able to have something to drink the morning of the first day after the procedure and, provided there are no post-operative complications, you will follow a standardized diet plan over the next three days under the guidance of a dietician. A sample main course after three days would be 2 soup spoon of broccoli mousse, 2 soup spoon of mashed potatoes and 2 soup spoon of pureed fish. This amount will make you feel full. The evening after your operation you can sit on the edge of the bed or in an armchair. You will be able to get up frequently the following day and can go for a walk in the corridor. Your wound does not require special care; the five small incisions (cuts) are covered with a waterproof film so you can have a shower on the third day. As after any operation, an antithrombotic drug will be injected into your leg subcutaneously every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. You will be able to go home on the fourth or fifth day after your operation.
When you leave the clinic you will be free of pain, able to get around independently and will not normally require any nursing care. For 21 days after the operation you will give yourself a daily subcutaneous injection (under the skin) to prevent thrombosis or pulmonary embolism. You will also take an antacid (medicine that neutralizes acid in the stomach) for a month after gastric bypass surgery and possibly for longer after sleeve gastrectomy. After both procedures, you will notice that the amount of food you can eat is significantly reduced. Many patients initially feel tired and weak as a result. This changes quickly, however, with the patient’s motivation and enjoyment of their “new life” increasing with every kilo that they lose. On average, patients are able to fully resume work three weeks after being discharged from the clinic. They are also able to start participating in any kind of sport at the same time.
Lifelong medical check-ups are required after these procedures, particularly after gastric bypass surgery. There is an initial check-up after three months and follow-ups after six and 12 months, after which annual check-ups are generally recommended. Particular attention will be paid to possible vitamin and mineral deficiencies. If patients have diabetes, high blood pressure or other weight-related diseases, the relevant medication can usually be quickly reduced under medical supervision and then frequently stopped completely.
The massive reduction in weight produces excellent results not just for your health but also for your personal well-being and social integration. There is little or no negative impact on your quality of life and patient satisfaction is very high. When I see my patients months after the procedure, they almost always ask me the same question: “Why didn’t I have the operation earlier?”
The lowest weight is achieved around two years after the operation and, apart from minor fluctuations, will then remain stable. If the outcome does not meet expectations or is not in line with the prognosis, additional measures may be considered. This applies to sleeve gastrectomy in particular, since we assume that a number of patients will need to have the sleeve converted to a gastric bypass after this period.
At this stage, patients may also wish to have excess skin removed – especially on their stomach, upper arms and thighs. Reports from patient self-help organizations on the quality of our treatment are also very positive.
Thyroid surgery is required to treat hyperthyroidism (overactivity of the thyroid gland) or tumours. There are various types of thyroid cancer; most occur during young adulthood and can generally be cured. Treatment involves removing part or usually all of the thyroid gland and radioactive iodine therapy. In the case of hyperthyroidism, radioactive iodine therapy alone is not usually sufficient; some or all of the thyroid gland generally needs to be removed as well. The patient is then cured.
If a patient has a palpable nodule (lump), an operation should be considered. A suspicious nodule should always be removed. Surgery is also recommended if the nodule increases in size or in the event that it presses on the trachea (leading to breathing problems) or causes swallowing difficulties.
If thyroid scintigraphy has been performed and shows what is known as a cold nodule, this means that the thyroid tissue in this area is not functioning normally. Scintigraphy is an imaging technique in which a very small, safe dose of radioactive iodine is administered to the patient. The substance accumulates in the thyroid tissue and enables various thyroid disorders to be diagnosed using a gamma camera, which produces photo-like images of the radiation emitted. The cold nodule may be either a malignant tumour or degenerated tissue. Since it is not generally possible to distinguish with certainty between the two without surgery, an operation is required.
Finally, hyperthyroidism that cannot be controlled by drugs (e.g. Graves’ disease) and generalized enlargement (goitre) need to be treated by surgical removal of the gland, especially if the thyroid extends into the chest cavity.
Any new palpable nodule in the thyroid region should always be assessed, particularly if it is observed to increase in size. A visible or palpable enlargement of the entire thyroid gland (goitre) may sometimes occur and should also be investigated by a specialist. Occasionally, tumours – especially if malignant – can cause damage to the vocal cord nerve, resulting in lasting hoarseness.
On the other hand, hyperthyroidism and its related symptoms can also occur without any noticeable enlargement of the thyroid gland. This generally leads to symptoms such as increased sweating, nervousness, possibly slight shakiness and in some cases to exophthalmos (bulging eyes). If you are experiencing one or more of the signs described, we strongly recommend that you consult a doctor.
Depending on its size, a nodule on the thyroid gland may already be visible and is generally palpable (a normal thyroid cannot be felt). A blood test will show whether you have an overactive or underactive thyroid. However, it cannot detect malignant tumours since thyroid function is usually normal even when a tumour is present. An ultrasound scan of the thyroid is always needed and enables the size and number of nodules as well as their “contents” to be seen. Tumours are more likely to be found in solid nodules (filled with tissue) than in cystic formations (filled with fluid). A needle puncture and microscopic examination of the cell material obtained are occasionally necessary. Thyroid scintigraphy (see above) is particularly useful for investigating thyroid dysfunctions. These investigations are almost always sufficient to diagnose the disorder and plan appropriate treatment. A laryngoscopy is performed by an ear, nose and throat specialist the day before the operation and allows the vocal cords and vocal cord nerve responsible for their function to be examined.
Most of the investigations will be arranged by your GP or an endocrinologist (gland specialist). The investigations will lead to either a definitive diagnosis or a well-founded clinical suspicion. You will then attend our clinic for a consultation at which we will discuss the treatment plan with you. If a tumour is suspected, we will inform you about the important decisions to be made, some of which will only be able to be taken during the operation.
The procedure begins with the removal of the half of the thyroid gland that contains the nodule. The tissue removed is then immediately examined under the microscope. If a malignant tumour is detected, the other half of the thyroid is also removed. This is done so that – as in most cases of malignant thyroid tumours – the appropriate treatment with radioactive iodine can be started after the operation. The purpose of this treatment is to eliminate any tumour tissue outside the thyroid gland (e.g. lymph node metastases). If the healthy half of the thyroid (the half not affected by the tumour) was left during the operation, all the radioactive iodine would accumulate there and have no effect on any metastases. In the case of diffuse enlargement of the thyroid (goitre), the entire thyroid gland is usually removed. If the thyroid gland is overactive, either the entire thyroid (e.g. in the case of Graves’ disease) or sometimes just half (e.g. in the case of autonomous adenoma) is removed.
Main procedures
Additional measures
Depending on your age and general state of health, you will be admitted to the clinic the day before your thyroid gland surgery or on the day of the operation itself if the situation is not critical. In any event, we need to perform the preliminary investigations required for the anaesthetic (ECG, blood test, and depending on your age possibly also a chest X-ray) close to the time of the operation. Patients with an overactive thyroid may need to undergo preparatory treatment to reduce the risks several weeks before the operation. Soon after you have been admitted, the anaesthetist will see you to discuss the anaesthetic method that will be used (general anaesthetic). You can usually continue to eat and drink up to six hours before the procedure.
Thyroid surgery can only be performed under general anaesthetic. A horizontal incision measuring approx. 6 cm is made across the neck, about a thumb’s width above the breastbone. A thin muscle layer is pulled to one side, revealing the thyroid gland. After the thyroid lobe has been exposed on the relevant side, the blood vessels leading to and from this side are tied and severed. To protect the important vocal cord nerve, it is located and electrically stimulated (see below) to check that it is functioning properly. Only then is the half of the thyroid gland to be removed lifted from the trachea and the bridge of tissue joining it to the other half severed. The tissue removed is immediately examined by a pathologist to determine whether it is malignant. In this intraoperative frozen section analysis, the pieces of tissue removed during the procedure are frozen, cut into very thin slices and examined under the microscope.
The pathologist can then accurately determine within 15 to 20 minutes whether the tumour is malignant or benign. If no malignant tumour is present, the operation can be completed by closing the wound in layers. If a malignant tumour is detected, the other half of the thyroid gland is removed in the same way. Once again, great care is taken to protect the vocal cord nerve. Depending on the type of carcinoma, lymph nodes in the surrounding area may also need to be removed at the same time. If the procedure is being performed to treat goitre or hyperthyroidism, both halves of the thyroid gland will usually need to be removed (total thyroidectomy).
Intraoperative function testing of the vocal cord nerve involves using a probe to transmit a fine electrical impulse directly to the exposed recurrence nerve during the operation. If the nerve is intact, it passes the impulse on to the larynx and from there to an electrode in the ventilation tube in the trachea (which is needed for the general anaesthetic). The impulse is transmitted via a cable to a neuromonitoring device, which emits an acoustic signal. If the nerve is intact, a typical beep sound is normally heard.
Thyroid surgery takes around 90 minutes if only half of the thyroid gland is removed or approx. 120 minutes if the entire thyroid gland is taken out. We can ensure very favourable cosmetic results by making the incision as short as possible and placing it along a crease line in the skin. To close the wound, we employ a technique using resorbable thread (which can be absorbed by the body) so that the stitches are not visible and do not need to be removed. Approximately one year after the operation, the scar is hardly visible.
The most feared complication is damage to the vocal cord nerve, causing hoarseness. If the vocal cord nerves on both sides were to be damaged, this could lead to serious breathing difficulties. Fortunately, these complications are very rare (the risk of the nerve being damaged on one side is approx. 1.2%, while the risk of damage to both sides is less than one in a thousand). Temporary weakening of the vocal cord nerve is a more common occurrence, resulting in changes to (usually a deepening of) the voice and voice fatigue (the voice becomes weaker with increasing use). This situation may last for two to three months before returning to normal. Post-operative bleeding at the wound site (within the first 12 hours) is very rare but since it may affect breathing, patients are kept on the monitoring ward for the first night after the procedure. Finally, temporary dysfunction of the parathyroid glands may occur, resulting in a drop in calcium levels in the blood (marked by a tingling sensation in the hands and around the mouth). This is caused by unintentional removal of the very small parathyroid glands (2 to 3 mm) during thyroid surgery. Calcium must be administered to counteract the after-effects, which always disappear within a few days or weeks.
Recovery is usually fast and uncomplicated. You are likely to experience slight pain around the wound or when swallowing in the first two to three days after surgery, but this can be relieved by standard painkillers. You will be able to get up and eat soft food on the same day as your surgery.
We cover the wound with a transparent film (which remains in place for seven days), saving you from the unpleasant task of having your dressing changed. There is also no need for you to have stitches removed since we use sutures under the skin that cannot be seen and dissolve there. We do not insert tubes to drain the wound.
As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. On average, patients stay in the clinic for three days.
You will be able to look after yourself without much assistance, if any, when you are discharged from the clinic. You may experience symptoms of an underactive thyroid (e.g. tiredness, constipation, feeling the cold easily, low blood pressure, weight gain) until we have found the right dose of thyroid hormone for you. These symptoms can quickly be relieved once the correct dose of medication has been found. Depending on the type of procedure and your age, you will be able to return to work approximately two weeks after you have been discharged from the clinic. You can then also resume all sports activities.
If the operation was performed to treat a malignant thyroid tumour, patients will be given additional treatment with radioactive iodine in a nuclear medicine clinic soon after surgery (after around one to four weeks) and will need to be admitted for a brief period. The purpose of this treatment is to eliminate any tumour tissue that may have been left behind – either of the thyroid gland itself or metastases (tumour cells that have spread) in the lymph nodes. It involves administering a small amount of radioactively labelled iodine; this treatment is not usually associated with any side effects. After a maximum of one year, thyroid scintigraphy (an imaging technique) will be performed as part of tumour aftercare and is a very reliable follow-up tool.
Patients who have had their entire thyroid gland removed will need to take the thyroid hormone L-thyroxine (e.g. Eltroxin®) after surgery for the rest of their lives to replace the hormone produced by the thyroid. This treatment is easy to perform. The required dose is set for each patient individually, but can easily be checked and adjusted by the patient’s GP. Patients who have had only half of their thyroid gland removed need to be checked to determine whether they are producing sufficient hormone. If not, they will also need to take L-thyroxine.
The prognosis is very good for the most common thyroid tumours, with it being possible to cure around 90% of patients nowadays. Moreover, the relapse rate for operations to treat hyperthyroidism is very low.
The only effective treatment for hyperparathyroidism (overactivity of the parathyroid glands) – which causes elevated calcium levels in the blood, resulting in kidney stones and rapid osteoporosis – is the removal of one or all four parathyroid glands. Malignant tumours of the parathyroid gland are extremely rare. Many years ago I developed a minimally invasive technique for this operation, which enables surgery to be performed through an incision measuring a maximum of 2 cm.
The parathyroid glands, which are about the size of a lentil, produce a hormone (parathormone) that regulates calcium levels. When this hormone is released, calcium is removed from the bones (calcium deposits); this causes the calcium level in the blood to rise. The excessive formation of benign parathyroid tissue can result in an adenoma and thus the uncontrolled secretion of parathormone (diagnosis: primary hyperparathyroidism). An adenoma is a benign lump that originates in glandular tissue and produces parathyroid hormone. It is typically not subject to normal regulation and is known as an autonomous adenoma. This leads to overproduction of the hormone with symptoms of illness. The increased secretion of parathormone causes the calcium level in the blood to rise disproportionately; as a result, kidney stones often develop and there may also be other symptoms. This is the most common reason why patients need surgery to remove a parathyroid gland.
Patients with chronic kidney disease may experience calcium deficiency due to reduced vitamin D activation. The parathyroid glands then react appropriately by increasing the secretion of parathormone (secondary hyperparathyroidism). This condition needs to be treated with medication rather than surgery. If secondary hyperparathyroidism persists over a long period of time, however, chronic overstimulation of the parathyroid glands may lead to uncontrolled and excessive secretion of parathormone (tertiary hyperparathyroidism). This requires surgical treatment, which involves the removal of all four parathyroid glands while retaining a small piece of tissue.
Possible consequences of hyperparathyroidism include loss of bone density due to the increased amount of calcium released from the bones, kidney stones caused by the increased amount of calcium excreted in the urine, calcification of blood vessels due to calcium and phosphate deposits, and a host of other varying symptoms. The diagnosis is most frequently made when a patient is newly diagnosed with kidney stones. Often, a blood test performed for another reason (such as a medical check-up) incidentally shows an elevated calcium level, with further investigations leading to the diagnosis. The patient does not usually exhibit any symptoms (yet).
In addition to an increased level of calcium in the blood, an elevated parathormone level must also be established. This confirms the diagnosis, with the aim of all further investigations only being to identify and locate the overactive parathyroid gland. The investigations required include an ultrasound scan and, most importantly, parathyroid scintigraphy with CT fusion. Scintigraphy is an imaging technique in which a very small, safe dose of radioactive substance is administered to the patient. The substance accumulates in the parathyroid tissue and enables location of the parathyroid adenoma using a gamma camera, which produces photo-like images of the radiation emitted. A laryngoscopy is performed by an ENT (ear, nose and throat) specialist the day before the operation and allows the vocal cords and vocal cord nerve responsible for their function to be examined.
After these investigations have been carried out, I will see you during my consultation hours to discuss the diagnosis and treatment with you. Treatment for primary hyperparathyroidism involves an operation to remove the overactive parathyroid gland. If the location of the adenoma has been determined by the preliminary investigations, I can perform the procedure through a very small incision (of around 1.5 cm).
In the case of tertiary hyperparathyroidism, all four parathyroid glands will need to be removed. This requires making an incision as described for thyroid surgery (see above). In certain situations, medical treatment with cinacalcet (e.g. Mimpara) is a possible alternative, for example until the operation is performed.
Main procedures
Additional measures
Depending on your age and general state of health, you will be admitted to the clinic the day before the operation on your parathyroid gland or on the day of the procedure itself if the situation is not critical. In any event, we need to perform the preliminary investigations required for the anaesthetic (ECG, blood test, and depending on your age possibly also a chest X-ray) close to the time of the operation. Soon after you have been admitted, the anaesthetist will see you to discuss the anaesthetic method that will be used (general anaesthetic). You can usually continue to eat and drink up to six hours before the procedure.
Most humans have four parathyroid glands located behind the thyroid, with one gland in the upper part and one in the lower part of the thyroid lobe on both the right and left sides. There can be significant variations in normal anatomy, however; the small parathyroid glands, which are about the size of a lentil, may be positioned slightly higher up or lower down and may even be at a considerable distance from the thyroid. This can sometimes make it difficult and time-consuming to locate the parathyroid glands, particularly when they are not significantly enlarged.
If parathyroid scintigraphy with CT fusion before the operation clearly shows the location of the adenoma, the procedure can be performed quickly and efficiently. A horizontal incision measuring approx. 1.5 cm is made in the front of the neck, on either the left or right side, above the suspected gland. After a cut has been made through the subcutaneous fat tissue, the muscle layer is pushed to one side and the edge of the thyroid gland becomes visible. If the parathyroid adenoma is enlarged (to 12 mm, for example), as is usually the case, it can be felt lower down and released from the surrounding tissue. The vocal cord nerve, which is usually located nearby, is identified and stimulated electrically to test its function (see below). The parathyroid gland is then removed and examined by frozen section analysis performed by a pathologist. In this intraoperative frozen section analysis, the pieces of tissue removed during the procedure are frozen, cut into very thin slices and examined under the microscope.
The pathologist can then accurately determine within 15 to 20 minutes whether the specimen is parathyroid tissue. In addition, a blood test is done 15 minutes after the parathyroid gland has been removed in order to determine the parathyroid hormone, which must show a 50% decrease compared with the initial value. If this is not the case, another adenoma must be present – this is unusual and means that a slightly larger incision must now be made to identify and remove the second adenoma. The operation is then completed by closing the wound in layers.
As access is required to all four parathyroid glands, an incision is made as described for thyroid surgery. The four glands are exposed and then removed apart from a small piece of tissue (this is known as a subtotal or 3 ¾ parathyroidectomy) to ensure that the patient’s parathyroid function continues as normal. Alternatively, total parathyroidectomy with reimplantation of a small amount of parathyroid tissue in the neck muscles (or forearm) is another option. I prefer 3 ¾ parathyroidectomy, which I have been performing with a good success rate for many years.
Intraoperative function testing of the vocal cord nerve involves using a probe to transmit a fine electrical impulse directly to the exposed recurrence nerve during the operation. If the nerve is intact, it passes the impulse on to the larynx and from there to an electrode in the ventilation tube in the trachea (which is needed for the general anaesthetic). The impulse is transmitted via a cable to a neuromonitoring device, which emits an acoustic signal. If the nerve is intact, a typical beep sound is normally heard.
Intraoperative frozen section analysis involves a pathologist examining tissue under the microscope during the operation. The pieces of tissue removed during the procedure are frozen, very thinly sliced and examined under the microscope. The pathologist can then accurately determine within 15 to 20 minutes whether the specimen is parathyroid tissue.
Parathyroid surgery can only be performed under general anaesthetic. Parathyroid adenoma removal takes 30 to 60 minutes, while 3 ¾ parathyroidectomy takes around two hours.
The range of possible complications are the same as those after thyroid surgery (see section on thyroid surgery). In addition, particular mention should be made of possible temporary dysfunction of the parathyroid glands, resulting in a drop in the calcium level in the blood (marked by a tingling sensation in the hands and around the mouth). This is particularly likely to occur after 3 ¾ parathyroidectomy in patients with tertiary hyperparathyroidism. To correct this dysfunction, patients will need to take calcium and possibly also calcitriol (e.g. Rocaltrol®). The latter improves the absorption of calcium from the intestine. It may take several weeks or even months for the situation to return to normal.
Recovery is usually fast and uncomplicated. You are likely to experience slight pain around the wound in the first few days after surgery, but this can be treated by standard painkillers. You will be able to get up and eat soft food on the same day as your surgery. The wound is covered with a transparent film (which remains in place for seven days), saving you from the unpleasant task of having your dressing changed. There is also no need for you to have stitches removed since we use sutures under the skin that cannot be seen and dissolve there. We do not insert tubes to drain the wound. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. On average, patients stay in the clinic for one to two days.
You will be healthy and able to take care of yourself when you are discharged from the clinic. You are unlikely to require painkillers and do not need to follow a special diet. Depending on the type of procedure and your age, you will be able to return to work approximately one week after you have been discharged from the clinic. You can then also resume all sports activities.
No special check-ups are required after surgery to treat primary hyperparathyroidism. Long-term medical treatment is usually needed following surgery to treat tertiary hyperparathyroidism due to the chronic kidney disease that caused the hyperparathyroidism.
Patients with primary hyperparathyroidism are cured when the operation is performed correctly. The risk of relapse is virtually zero. In the case of tertiary hyperparathyroidism, the situation is generally corrected in terms of the previous overactivity of the parathyroid glands. However, there is a certain risk of long-term underactivity or of a subsequent relapse.
A hernia is a defect in the supporting layers of the abdominal wall (or in the diaphragm) which may inborn or caused by a previous operation. Parts of internal organs may protrude out of the abdominal cavity through the hernia defect (opening) that develops; this usually results in the presence of a visible bulge (not seen with hiatus hernias).
Hiatus hernia: see procedures on the oesophagus.
Patients who have been diagnosed with an inguinal, umbilical or incisional hernia would be well-advised to have it repaired by surgery in due time. If surgery is postponed the hernia will become larger over time, making the results of the operation likely to be less satisfactory. Moreover, the contents of the hernia may suddenly become trapped and strangulated (involving a loss of blood supply) – by bowel loops for example. This requires an emergency operation, possibly involving the removal of parts of the intestine: an unnecessary increased risk.
Inguinal hernias are very common disorders, particularly in men. Incisional hernias, i.e. a defect in the abdominal wall that occurs in the scar of a previous surgical incision, are also common. Umbilical hernias are usually inborn and often remain undetected for a long time.
Patients only notice the problem when they see or feel a new bulge in their groin, around their navel or in an old surgical scar. This is often accompanied by moderate to strong pain which worsens with physical activity. If you experience these symptoms, we recommend that you consult a doctor. We would be happy to examine and advise you at any time.
Inguinal, umbilical and incisional hernias are usually easy to diagnose by medical examination. If there is uncertainty about the diagnosis, an ultrasound scan can provide clarification. In rare cases – if a patient has a very large incisional hernia, for example – a CT (computerized tomography) or MRI (magnetic resonance imaging) scan is desirable in order to aid planning of the operation.
As soon as the diagnosis has been made – usually at your first appointment – I can discuss the treatment with you in detail. We recommend that you have surgery within a maximum of 3 months.
In the case of inguinal hernias, consideration should be given to factors such as anaesthetic risks and previous operations as well as the patient’s wishes and needs when deciding which surgical technique to use.
I normally recommend laparoscopic hernia surgery with a mesh implant – a synthetic mesh developed for the reconstruction of anatomical layers. The mesh is made of a material such as biocompatible polypropylene, for example, which is very well tolerated. Modern mesh implants are very fine lightweight fabrics that are loosely woven, with the result that they are readily accepted by the body and optimally increase tissue strength in the long term. However, laparoscopic hernia surgery requires a general anaesthetic – for good reason – and the insertion of a synthetic mesh.
At your explicit request, the procedure may be performed under regional anaesthetic (injection close to the spinal cord) or even local anaesthetic (injection into the part of the body on which surgery will be performed) instead of a general anaesthetic. In this case, however, surgery cannot be carried out laparoscopically. At your request, the operation can also be performed without an implant (but again, not laparoscopically). However, you will need to accept that the results may be slightly compromised.
In the case of incisional and umbilical hernias, I can comply with your individual requirements to only a limited extent. In the case of relatively small incisional hernias and virtually all umbilical hernias, I recommend laparoscopic surgery. To repair medium-sized and large incisional hernias, however, open anatomical reconstruction of the abdominal wall is required. A synthetic mesh almost always needs to be inserted when incisional hernias are repaired, but small umbilical hernias can be repaired without a mesh.
Inguinal hernia (including femoral hernia)
Umbilical hernia
Incisional hernia
For most hernia procedures, it is sufficient – depending on your general state of health – for you to be admitted to the clinic on the day of your operation. In this case, however, the preliminary checks required for the anaesthetic (ECG, blood test, chest X-ray) will need to be done beforehand by your GP. If you are having a large incisional hernia repaired or there are anaesthetic risks, we recommend that you are admitted the day before your operation. Shortly after you have been admitted, the anaesthetist will discuss with you the anaesthetic method that will be used. Depending on the type of anaesthetic, we will inform you in good time about how long you can still eat and drink before the procedure.
If you have an inguinal, umbilical or relatively small incisional hernia, I generally recommend the minimally invasive laparoscopic technique. This method, also known as keyhole surgery, is performed under general anaesthetic and involves inserting optical and surgical instruments into the abdominal cavity through small incisions in the abdominal wall. A device known as a trocar is usually inserted near the navel. This is an airtight tube (equipped with a valve) measuring approximately 10 to 15 cm in length and 5 to 12 mm in diameter through which a video camera, surgical instruments and the mesh implant can be introduced into the abdominal cavity. The laparoscopic procedure means that patients can avoid a large incision, pain and unattractive scarring. Although a general anaesthetic and mesh implant are necessary, both the short-term and long-term results are excellent. This type of procedure results in very little acute pain and virtually no chronic pain, and the recurrence rate (the risk of recurrence of the hernia) is very low. Another advantage is that hernias on both sides can be operated on simultaneously in a minimally invasive way without any additional incisions.
A video camera is inserted into the abdominal cavity through a small incision near the navel. Two more small incisions are required – one for each of the surgical instruments in the operator’s right and left hands. Being able to see inside the groin enables the surgeon to determine the size and type of hernia and whether a second hernia is present on the opposite side. The peritoneum (a thin and transparent layer of tissue in the abdominal cavity, which lines the abdominal wall and also most of the abdominal organs like wallpaper) is then opened to approximately 10 cm and separated from the abdominal wall; the hernia sac is released in the same manoeuvre. The nerves and vessels in this region – and the vas deferens in men – can be seen perfectly and thus avoided. Once enough space has been made, a mesh implant measuring 10 x 15 cm is inserted into the surgical site through the trocar (see above) and positioned so that it covers the hernia opening with a generous overlap. The mesh is then fixed using a small number of staples, which can be absorbed by the body, and the peritoneum is carefully closed over the mesh with a suture. After the instruments have been removed, the small incisions in the skin are then also closed with an intracutaneous suture (just below the surface of the skin). The operation takes just under 60 minutes for one side or 90 minutes for both sides.
A video camera and two surgical instruments are inserted through small incisions in the flank (usually on the left side). Any loops of intestine and the adhesions of internal fat that are normally present are separated from the hernia sac. It is only then that the size of the defect becomes apparent. The hernia sac is removed. A mesh implant measuring a minimum of 12 x 12 cm (and a maximum of 25 x 30 cm) that is suitable for use in the abdominal cavity is then inserted through the trocar (see above). The mesh is fixed to the abdominal wall internally – with a generous overlap of the hernia opening – by four sutures, one at each corner of the mesh. In addition, the edge of the mesh is fixed to the peritoneum/abdominal wall internally using staples that can be absorbed by the body. Finally, the three incisions are closed with an intracutaneous suture (just below the surface of the skin). The operation takes around 60 minutes.
If laparoscopic surgery is not suitable (if the patient has previously had open prostate surgery, for example, or if there is an increased anaesthetic risk) or the patient would prefer not to have it (if he/she wants to avoid a general anaesthetic or would like to have implant-free surgery), an alternative method may be chosen. The operation can then also be performed under regional or local anaesthetic. An incision measuring around 7 to 8 cm in length is made just above the inguinal fold (inguinal incision). After the fascia (band of connective tissue) has been opened, the hernia sac is exposed and removed. The hernia opening is then closed by joining together the existing layers of muscle and fascia (layers of connective tissue) with a suture (Shouldice repair) or by sewing in place a synthetic mesh measuring about 12 x 8 cm (Lichtenstein repair). These types of procedure take just under 60 minutes.
No mesh implant is needed for small umbilical hernias where the diameter of the hernia opening is less than 2 cm. These types of defect can be exposed by a semicircular incision in the skin below the navel and then closed with a suture. This takes only around 30 minutes; a short general anaesthetic is needed.
For large incisional hernias, in particular, the laparoscopic technique is frequently unsuitable because of its unsatisfactory results in such cases. With this type of hernia, the old wound generally needs to be reopened and the defect in the abdominal wall completely exposed. The individual layers of the abdominal wall are then opened on both sides. The innermost layer of fascia (layer of connective tissue), which is now mobile, is subsequently closed with a suture. A synthetic mesh of the required size (maximum size approx. 25 x 15 cm) is then sewn onto this layer and the anterior abdominal wall layers are closed over the mesh (Rives repair). A general anaesthetic is always required for this procedure, which takes around 90 minutes.
The risk of complications associated with hernia surgery is low; for all procedures as a whole, the risk is approximately 3%. There is a small risk of haematoma (localized collection of blood), wound infection (very rare) and/or post-operative pain as after any kind of operation.
Laparoscopic surgery has a significantly reduced risk of pain, especially chronic pain. By contrast, the main disadvantage of conventional inguinal hernia operations (Shouldice or Lichtenstein repair, for example; see above) is that a considerable proportion of patients (up to 10%) suffer from varying levels of long-term pain. Since, no matter what technique is used, the procedure is performed near to the spermatic cord in men, there is a very slight risk (less than 1%) of the vas deferens or testicular blood supply being affected.
The types of complication are the same as those associated with incisional hernia surgery, but they are experienced far less frequently due to the size of the wound area being considerably smaller.
Both laparoscopic and open surgery result in pain that requires treatment (painkillers) in the first few days after the procedure. This pain is frequently caused by the type of mesh fixation in laparoscopic hernia repair and by the size of the (internal) wound area in open hernia repair. Most patients do not experience any problems in the medium to long term, however. Since the operation is performed through the abdominal cavity (laparoscopy) or the abdominal cavity is opened (open surgery), there is a hypothetical risk of injury to the intestine when adhesions are removed; this is a rare occurrence, however. Fortunately, wound infections and haematomas are also very rare after these types of operation.
After the operation you will spend a few hours in the recovery room before being taken to your room. We place great emphasis on effective pain relief. Pain is not generally a problem after inguinal hernia surgery. Slightly more treatment is required after large incisional hernia repair, but any issues can always be resolved to the patient’s satisfaction. After inguinal hernia surgery, you can get up and walk around on the same day; if you have had a large incisional hernia repaired, you will generally be able to do so the following day. You can eat and drink again the evening after the procedure. Since the small incisions in your skin are closed with an intracutaneous suturing technique (just below the surface of the skin) and covered with small transparent films, you do not need to have any dressings changed or stitches removed. This also means that you can shower the day after your operation. As after any operation, an antithrombotic drug will be injected into your leg subcutaneously every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms.
If you have had surgery to repair an inguinal or umbilical hernia, you will be able to go home one to two days after the operation. If you have had a large incisional hernia repaired, you will need to stay in the clinic for up to five days.
You will be completely mobile and able to take care of yourself when you go home. If you have had inguinal or umbilical hernia surgery, you will need to continue to take low doses of painkiller for just a few days. If you have had surgery to repair a large incisional hernia, you may need to take painkillers for slightly longer. You should not lift or carry anything heavier than 7 kg for at least 14 days after inguinal hernia surgery or for six to eight weeks if you have had a large incisional hernia repaired. You should also avoid any kinds of sport that put heavy strain on your abdominal muscles during this period. How soon you can return to work depends on the kind of work you do. You can return to an office job four to five days after the procedure. If your job involves physical activity, you will generally need to take at least two weeks off work.
Apart from avoiding physical exertion as mentioned above, no additional treatment is necessary. Since we close the incisions in the skin with an intracutaneous suture (just below the surface of the skin), there are no stitches to be removed. I will see you at least once for a check-up during my consultation hours, usually after about six weeks. No additional check-ups are required.
Nowadays the results of inguinal, umbilical and incisional hernia surgery are excellent. The risk of recurrence (an inguinal hernia reoccurring in the same place) after an operation to repair an inguinal or umbilical hernia is approximately 1 to 3%. The recurrence rate for incisional hernias can be slightly higher, depending on the size of the defect and the condition of the abdominal wall.
Disorders that affect the anus are also known as proctological diseases. They are very common. An operation is needed for a number of diagnoses, in particular haemorrhoids, fistulas and fissures, and these will be discussed below.
Haemorrhoids are a kind of “varicose veins” in the anus. They are normal up to a certain size. If they become too large, however, they may cause problems. If treatment with suppositories or other non-operative methods is unsuccessful, an operation is required. Fistulas are abnormal connections between the anus or rectum and the skin near the anus and are probably inborn. They can remain undetected for a long time and usually only become apparent when an abscess (collection of pus in the fistula) forms. An operation is generally unavoidable. Fissures are fine linear tears of the skin in the anus. The reason why they develop is not entirely clear. It is advisable to treat fissures with suppositories and ointments in the first instance; if this does not achieve the desired result, a surgical procedure is required.
Recurrent bleeding from the anus, which is usually painless, is a typical sign of haemorrhoids. Larger prolapsed haemorrhoids can also be felt, sometimes causing “mechanical” irritation and subsequently pain. An operation is needed if the patient is troubled by the situation and experiencing pain.
Occasionally, the presence of a fistula is indicated by the slight and recurrent discharge of secretions or pus near the anus (causing stains in the underwear). More frequently, however, secretions accumulate in the fistula – which had previously been undetected – and cause an abscess (collection of pus) to form. Surgery is always needed when a fistula is diagnosed; the timing of the operation depends on the level of suffering that the patient is experiencing.
Sharp pain in and around the anus when passing stools, often lasting for several minutes or even hours afterwards, is a typical sign of fissures. Patients feel a burning sensation in the anus. In addition, constipation is usually an after-effect due to the patient’s fear of painful bowel movements. An operation is needed if the fissure does not heal despite the use of suppositories and ointments and the patient continues to experience pain.
To investigate haemorrhoids, fistulas and fissures, an anoscopy (visualization of the anus) is required. This simple outpatient examination of the anus and lowest portion of the rectum (for which no preparation is needed other than possibly an enema) is performed using a short tube-shaped instrument with an integrated light source. This enables most proctological diagnoses to be made. The examination can be carried out by either a surgeon with proctological experience or a gastroenterologist. It goes without saying that I can also offer this examination during my consultation hours. In most cases, a diagnosis can be made straight away and treatment can be initiated. Additional examinations may be required in individual cases. To investigate fistulas, an endosonography (examination using an ultrasound probe inserted into the anus) or MRI (magnetic resonance imaging) is also recommended.
These procedures visualize the extent of the fistula, which is important for planning surgery. In certain situations – if patients are suffering from bowel incontinence, for example, meaning that they are unable to control the passage of stools through the anus, which regularly leads to involuntary bowel movements – the pressures of the anal sphincter muscles will need to be measured (anorectal manometry). If patients complain of blood in their stools, a full colonoscopy (visualization of the whole colon) should also be considered in order to rule out any source of bleeding in the colon, in other words a tumour.
After I have examined you during my consultation hours and made a diagnosis, or if you come to me with a diagnosis already made, I can discuss treatment with you and also initiate it. If additional examinations are necessary, a second appointment will be made for you. We will then discuss the necessity of the operation, the anaesthetic to be used, the surgical technique planned, possible complications, the length of your stay in the clinic, convalescence, any follow-up treatment and the time you will need to take off work.
Haemorrhoids:
Fistulas:
Fissures:
If you are having anal surgery, you may not need to be admitted to the clinic until the day of your operation, depending on your general state of health. In this case, however, the preliminary checks required for the anaesthetic (ECG, blood test, chest X-ray) will need to be done beforehand by your GP. If you are undergoing major proctological surgery or there are anaesthetic risks, it is recommended that you be admitted the day before the operation. Shortly after you have been admitted, the anaesthetist will discuss with you the anaesthetic method that will be used. Depending on the type of anaesthetic, we will inform you in good time about how long you can still eat and drink before the procedure. An enema will be given in preparation for the operation.
Most procedures on and around the anus can be performed under regional anaesthetic, i.e. spinal anaesthetic. A general anaesthetic is administered if the procedure is more complex or at the patient’s request.
Stapled haemorrhoidectomy as developed by Longo is the most common surgical technique for treating haemorrhoids. It uses a stapler that was originally designed to perform bowel connections (anastomoses). The principle of the operation involves severing and sealing the vessels supplying the haemorrhoids through the resection (surgical removal) of a 360° ring of mucosa from just above the anus; as a result, the haemorrhoids gradually shrink. The advantage of this operation is that there is no external wound and surgery is performed in an area of mucosa that does not contain any pain nerves; as a result, the patient suffers very little pain and the healing phase is uncomplicated.
First, the anoscope (a plastic tube measuring approx. 5 cm in length and with a diameter of approx. 4 cm) is inserted in order to protect the sphincter. A 360° suture (“purse string suture”) is then placed in the rectal mucosa just above the anal verge (where the anal canal meets the skin of the anus). The rod-shaped stapling device is then inserted and the suture is tied onto its central axis. After the mechanism of the device has been triggered, a 360° ring of mucosa is excised and at the same time a suture is placed using small titanium staples. The anoscope is removed and the procedure, which takes around 30 minutes, is then complete.
The first sign of a fistula is very often the formation of an abscess near the anus. The emergency procedure required (under anaesthetic) involves opening the abscess. The fistula causing the abscess is not usually visible at this time due to the inflammation and should not be removed when infection is present, as is the case here.
As soon as the abscess wound has healed (one to two months later), we will examine you during our consultation hours. We will then be able to see the fistula and it is now possible to plan definitive fistula surgery (additional examinations may be needed beforehand, as mentioned above). This involves completely removing the fistula provided there is no risk of damage to the sphincter. If the fistula runs through the sphincter, meaning that it cannot be removed, another approach must be taken. We then recommend laser obliteration with closure of the internal fistula opening, which involves inserting a thin laser probe into the fistula tract and obliterating it using a laser beam along its entire length. In addition, the fistula usually has an internal opening in the anus or rectum and this is covered by moving a small flap of skin or mucosa. The procedure lasts around 30 minutes; it can take several weeks before the healing process is complete.
Nowadays, we very rarely use seton drainage (placing a cord through the fistula tract for a number of weeks to allow the fistula to drain) or fistula plugs (inserting an implant into the fistula) to treat fistulas due to the large amount of discomfort caused to the patient and the disappointing results.
Fissures are extremely painful, which can cause spasms of the sphincter – and it is precisely these spasms that prevent healing. The treatment approach therefore aims to relieve these spasms. Treatment with suppositories and ointments should be tried initially. Nitroglycerin suppositories or ointments, for example, can relieve the sphincter spasms and help fissures to heal. If this is not the case, a Botox injection can be given.
A small dose of this neurotoxin (“nerve poison”) is injected into the internal sphincter, which prevents the muscle from spasming for several weeks. If this does not work either, meaning that the fissure is now considered to be a chronic fissure, surgical cleaning (debridement) is occasionally necessary; the sphincter may also need to be carefully dilated with a balloon catheter. The final option involves making a small cut in the internal sphincter, but this is a procedure that we very rarely need to perform.
All proctological procedures are associated with a – fortunately very small – risk of damage to the sphincter, leading to bowel incontinence. For this kind of operation, it is therefore advisable to choose a surgeon who is experienced in the field of proctology. External anal wounds – which are sometimes necessary in proctological procedures – virtually always heal, but it can take time (six to eight weeks). Although these wounds can never be kept completely clean, post-operative wound infections are extremely rare. The amount and type of post-operative pain experienced varies, depending on the patient, but can be well controlled with conventional painkillers (which will be needed for a few days).
There may occasionally be slight bleeding after the operation. In the first few days and weeks after surgery, bowel movement disorders may occur (stools being passed in several small portions, for example). In the long term, a few patients (approx. 5%) may redevelop haemorrhoids.
The main problem here is that it is not unusual for several operations to be needed before the fistula is definitively cured. Until the desired effect has been achieved, patients often suffer from variable discharge and pain, especially when sitting.
The rate of complications associated with these procedures is very low but, as with fistulas, several treatment stages are often needed before the fissure is healed.
Immediately after the procedure, we will give you enough painkillers for you to be able to cope well with the pain. Antibiotics are not generally required. You can get up and eat a normal diet straight away. We recommend that you take stool-regulating medicine at an early stage to make your stools soft, which will lead to less discomfort. If you have an external anal wound, we will show you how to rinse it in the bathroom. A sanitary towel in your underwear is a suitable wound dressing. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. You will be able to go home after one or two nights in the clinic.
You will normally be able to return to work within a few days of returning home. For some time, you may experience problems when sitting. It may then be advisable to consider temporarily installing a standing desk. If you have an external wound, you will need to rinse it twice a day, especially after bowel movements, and wear a sanitary towel in your underwear until it has completely healed. This may take six to eight weeks. You can resume light sports straight away.
Post-operative measures are generally limited to rinsing the anus and to taking stool-regulating medicine and painkillers if necessary. The most important thing is to remain patient until healing is complete. For this reason, your first follow-up check will not be until six weeks after surgery (unless you need to see us beforehand).
Since the medical conditions described are all benign, the prognosis is essentially good. As mentioned above, however, a number of proctological complaints can recur persistently. Nevertheless, the situation can be brought under control with consistent treatment.
Operations on the stomach are required for benign and malignant tumours; surgery is also occasionally needed to treat ulcers – defects in the lining of the stomach (ulcus ventriculi) or duodenum (ulcus duodeni) of different sizes and depths – but primarily to treat their complications (bleeding, perforation). Ulcers may be caused by an infection with the bacterium Helicobacter pylori; additional factors include excess acid production, use of certain medicines (e.g. anti-inflammatory drugs, cortisone, aspirin), circulatory disorders and psychosomatic problems. Smoking and excessive alcohol intake may make the situation worse. While operations on tumours usually involve a laparotomy (incision to open the abdomen), some procedures for ulcers can also be performed laparoscopically (in a minimally invasive way, also known as keyhole surgery; see below).
Stomach surgery for malignant tumours should only be performed at the appropriate clinics with an interdisciplinary team. Our surgical practice is part of Klinik Hirslanden. All the necessary specialists and technical prerequisites are available here, enabling us to offer operations of stomach at the very highest level. A key factor here is our (surgical) experience, but our empathy and sense of responsibility are also important aspects. I would be happy to see you during my consultation hours to provide advice and help plan your care, and will be with you every step of the way on this difficult treatment journey.
Patients with stomach or duodenal ulcers usually need an operation if complications occur that cannot be controlled by other measures. If patients have acute ulcer bleeding, the first step is to attempt to stop the bleeding by means of a gastroscopy (examination of the stomach). This is performed by a gastroenterologist (doctor who specializes in the digestive system). If the gastroscopy is unsuccessful, an operation is needed. Chronic inflammation of a stomach ulcer at the junction to the duodenum can result in a scarred narrowing of the pylorus (the opening from the stomach into the duodenum), leading to gastric outlet obstruction (in which the movement of food is blocked) and vomiting. The problem can usually only be resolved by surgery. Finally, ulcers can occasionally break through the wall of the stomach or, in particular, the duodenum; this is known as perforation and always requires emergency surgery.
Stomach tumours can be easily diagnosed by a gastroscopy and it is usually also possible to differentiate between benign and malignant tumours. For this examination a flexible endoscope about 10 millimetres thick is inserted through the mouth and throat to the oesophagus and stomach for inspection and potential removal of a tissue sample. No anaesthetic is necessary. In all cases an operation is indicated, either to clarify the diagnosis or for the radical removal of malignant tumours. Malignant tumours include cancer that starts in the stomach and also gastrointestinal stromal tumours (GISTs), which are far less malignant and do not just start in the stomach. GISTs start in the connective tissue of the gastrointestinal tract and mainly occur in the stomach and small intestine. Although they are classified as malignant tumours and also form metastases, patients have a chance of recovery if GISTs are detected at an early stage and are treated correctly; even if they are at an advanced stage, patients have a very long survival time. Treatment of GISTs always focuses on surgical removal of the tumour provided that this is possible. Treatment is frequently supplemented by the use of medication, which is often long-term.
Patients with benign tumours frequently do not experience any kind of symptoms. Benign tumours are therefore often diagnosed as incidental findings during examinations – such as ultrasound or computerized tomography scans – that are performed for another reason. Only when the tumours have become very large do patients sometimes experience a feeling of pressure in their stomach.
Patients with stomach or duodenal ulcers usually have a relatively long history of upper abdominal pain. They frequently also experience general symptoms such as nausea, vomiting, and feelings of pressure and fullness. Pain on an empty stomach, i.e. hours after eating or at night, is a classic symptom of a duodenal ulcer. Typically, the pain improves temporarily after eating (this is known as food relief). In many patients the disease is not detected until complications occur. Chronic bleeding can become apparent in the form of tar-like (black) stools and anaemia; the patient may also vomit partially digested blood (“melena”). Depending on its severity, acute bleeding can lead to a dangerous weakening of the circulatory system with dizziness, fainting and shock. The first symptom of a perforated ulcer is the sudden onset of intense stabbing pain in the upper abdomen followed by a rapid deterioration in the patient’s condition to the point of collapse.
A recurrent or continuous dull pain in the upper abdomen is often one of the first signs of malignant stomach tumours. The patient frequently also suffers from a loss of appetite (especially for meat) and, as a result, unintentional weight loss. If the tumour bleeds, this leads to anaemia and an associated lack of energy; stools may become black in colour. The food passage can sometimes become blocked, leading to vomiting.
A gastroscopy (examination of the stomach; see above) is the main investigative tool for diseases of the stomach and duodenum and frequently allows a diagnosis to be made. A biopsy (removal of a tissue sample) is almost always performed during the gastroscopy and enables a tumour to be identified under the microscope and classified. Histological differentiation between intestinal and diffuse stomach carcinomas is important when planning surgery (see below). The biopsy also allows any infection with a Helicobacter bacterium to be detected. However, Helicobacter can also be detected by a breath test, antibody test or antigen test in the stool.
If a tumour is present, the gastroenterologist will also perform an endosonography, i.e. an internal ultrasound: this involves inserting a small ultrasound probe into the stomach and duodenum using a gastroscope (an instrument used to visually inspect the interior of the stomach) and then examining the section affected by the tumour with the probe in direct contact with this section. This enables the gastroenterologist to accurately determine how far the tumour in the mucosa (lining) has grown into the deeper layers or even beyond. In addition, the gastroenterologist can check whether there are any enlarged lymph nodes near the tumour that may raise suspicions of metastases.
If a malignant tumour is present, a computerized tomography (CT) scan is always required before the operation in order to rule out distant metastases (in the liver or lungs). If an ulcer perforates, air escapes into the abdominal cavity; this can clearly be seen on the CT scan and is a warning sign. If distant metastases are found, surgery is not generally performed since it will be of no benefit to the patient.
I usually see patients with malignant stomach tumours after they have been referred to me by a GP, gastroenterologist or oncologist. The investigations required have then generally been performed and the diagnosis or suspected diagnosis has been made. If the patient has a malignant tumour, the treatment plan is first discussed at one of the interdisciplinary Tumour Board Meetings. Cases of this kind are discussed at these weekly meetings, which are held in competence centres for tumour treatment in the presence of all necessary specialists. The next treatment steps are subsequently proposed. A surgeon, oncologist, radiologist, radiotherapist, gastroenterologist, pathologist and possibly other specialists are present. I will then see you during my consultation hours and we will discuss the treatment plan together, in particular the operation planned, how long it will take, the necessity of the anaesthetic, the risk of complications and also therapy and care during your stay in the clinic. We will provide you with information about resuming a normal diet after the operation, mobility, wound care, how long you will stay in the clinic and the length of the convalescence period. We will also discuss the possibility of additional chemotherapy before and/or after the operation and what kind of long-term follow-up care you will receive.
Patients with stomach or duodenal ulcers are usually admitted to the clinic as an emergency, i.e. for an emergency operation. I will therefore see you in the emergency unit and we will discuss your situation and treatment there.
Operation for malignant stomach tumours
Operation for benign stomach tumours
Operation for stomach or duodenal ulcer or for its complications
If you are having planned surgery on your stomach (primarily to treat tumours), you will need to be admitted to the clinic a day before the operation. I will of course see you then and we will discuss any remaining questions. Depending on your general state of health and documentation, you may be examined by a doctor of internal medicine when you are admitted. You will always have a blood test and possibly also an ECG and lung X-ray if necessary. No special preparations are required. You will be given a light meal in the evening. The anaesthetist will discuss matters relating to the anaesthetic and post-operative pain treatment with you. You may drink until six hours before the procedure. If you are admitted via the emergency unit, you will first see the emergency doctors and then the necessary specialists. This could be the gastroenterologist or you may see the surgeon straight away. We will discuss the investigations, diagnosis and emergency operation with you there.
A general anaesthetic is always required for operations on the stomach and duodenum. Open surgery, i.e. a midline (vertical) abdominal incision, is usually indicated for procedures to treat tumours; operations for ulcers may also be performed using a minimally invasive, i.e. laparoscopic, technique with abdominal endoscopy (keyhole surgery). The parts of the stomach that have been removed are sent to the pathology department after the operation and are examined under the microscope there.
If a tumour is located in the upper third of the stomach and/or is a carcinoma of the diffuse type, the entire stomach will need to be removed. This involves sealing off the duodenum where it previously joined the stomach (“duodenal stump”). In addition, the lymph nodes nearby are removed at the same time. In rare cases, a large tumour may have grown into the spleen, pancreas or colon; the procedure must then be extended accordingly. To reconstruct the stomach that has been removed, a Jshaped pouch made from the small intestine is used to form a “replacement stomach” that is then sutured directly to the oesophagus. The procedure takes around three hours.
If the tumour is located in the middle or lower part of the stomach and is a carcinoma of the intestinal type, the lower third or lower two thirds of the stomach are removed. This involves sealing off the duodenum where it previously joined the stomach (“duodenal stump”). In addition, the lymph nodes nearby are removed at the same time. A loop of small intestine is pulled up and sutured to the remaining stomach. The procedure takes two to three hours.
If tumours are small to medium-sized and benign, the operation can also be performed using a minimally invasive laparoscopic technique. A video camera and rod-shaped instruments are inserted into the abdominal cavity through small incisions. The part of the stomach affected by the tumour is then severed with a stapler. This scissor-like device can grasp the stomach wall in steps of a maximum of 6 cm, cut through it and seal the cut surface on both sides using a large number of small titanium staples. The severed tissue (specimen) is then put into a plastic bag and retrieved through one of the existing small incisions, which can be enlarged according to the size of the stomach portion to be removed. The procedure lasts around one hour.
Patients’ general state of health can vary significantly. If the person is haemodynamically stable (no cardiovascular problems), surgery can be performed using a minimally invasive laparoscopic technique; if there are signs of blood poisoning (sepsis), an abdominal incision is necessary. The perforation site is always located at the outlet of the stomach where it joins the duodenum. The perforation is closed by suturing. If it is very large or is located on the back wall of the duodenum, it is sometimes necessary to remove the lower third of the stomach and seal off the duodenum (“duodenal stump”). These patients also receive antibiotics for peritonitis. The procedure takes one to two hours.
This operation is relatively rare nowadays and is usually performed as open surgery via an abdominal incision. These patients are at risk due to significant blood loss, meaning that the operation must be carried out quickly. The bleeding ulcer is almost always found in the bottom quarter of the stomach or in the uppermost portion of the duodenum, where we can see or feel it. The area where the stomach joins the duodenum is opened with a longitudinal incision. The bleeding ulcer is then visible and the bleeding is stopped by punctures (sutures). The incision in the stomach/duodenum is then closed. The procedure takes one to two hours.
The most serious early complication (in the first five days after surgery) is leakage from the suture connecting or closing the stomach or closing the duodenum. This can result in contents of the stomach, but in particular also bile and pancreatic juice, leaking into the abdominal cavity and causing an infection, which usually means that an emergency reoperation is required. This complication occurs in a few per cent of procedures. If a patient has a perforated stomach ulcer, there is also a risk of peritonitis and, despite treatment with antibiotics, the risk of other infectious complications (e.g. abscesses) is increased. Otherwise, the usual – but fortunately very rare – range of complications may occur, such as post-operative bleeding, pneumonia, infection of the bladder, wound infection, thrombosis, pulmonary embolism or incisional hernia.
After your entire stomach has been removed and after emergency surgery for bleeding or perforation, you will usually spend a night in the intensive care unit. All the necessary painkillers will be administered. You may need to have a gastric tube (a thin plastic tube that is passed down into your stomach through your nose and oesophagus) for the first one to two days. You will only be able to take small amounts of liquid in the first few days. Artificial feeding via an intravenous drip may be necessary at this stage. You will start to transition to a normal diet from around the third day after surgery. Once the first four days are over, you will usually make rapid progress and any abdominal drains – and, if all goes well, the drip – can then be removed. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. You may only need to stay in the clinic for around five days after a minimally invasive procedure; if your entire stomach has been removed, you can expect to stay for 10 to 12 days.
Depending on the extent of the procedure, any complications after the operation and your age and general state of health, you should consider going away to convalesce after you have been discharged from the clinic. You may initially find eating slightly more difficult than usual, but you do not need to follow a strict diet. You may feel very tired and weak at first. Light sporting activities can be resumed after around one month, or earlier after minimally invasive procedures. Depending on the diagnosis and procedure performed, you will be able to return to work after either two weeks or two months. You can expect to enjoy a normal quality of life in the medium term.
If patients have a malignant stomach tumour, the question of additional chemotherapy (treatment with medication) arises. As soon as the results of the examination under the microscope are available (around five days after the operation), the histopathological tumour stage can be determined. The situation is then discussed at the interdisciplinary Tumour Board (see above) and additional chemotherapy may be recommended in order to improve the prognosis. This is an outpatient procedure, usually lasts around three months and may be accompanied by (significant) side effects. Follow-up checks primarily depend on the patient’s symptoms. Very frequent and time-consuming check-ups are not absolutely necessary since treatment options are limited if the disease returns.
This does not apply to surgery for GISTs (gastrointestinal stromal tumours; see above). These tumours respond well to treatment if they do recur, and so regular check-ups are worthwhile. Patients who have had surgery for a benign tumour or a stomach or duodenal ulcer do not need any special follow-up treatment or checks.
Removal of the stomach almost always results in vitamin B12 deficiency, which can lead to anaemia. This vitamin will therefore need to be administered (by injection) about every three months for the rest of the patient’s life.
In the case of malignant tumours of the stomach, the prognosis is favourable if they are detected at an early stage but critical if the cancer is already advanced. Additional administration of chemotherapy, either before or after the operation, can improve the prognosis. After surgery for GISTs (gastrointestinal stromal tumours; see above), the prognosis is much better than in the case of conventional stomach tumours. Very well-tolerated medicines are available which must be taken in the long term and improve the prognosis even further. We can advise you on this.
For patients who have had surgery for a stomach or duodenal ulcer, the prognosis is generally very good. The medicine that may have caused the ulcer should be avoided and an antacid may need to be taken in the long term.
Operations on the oesophagus (or the junction where the oesophagus meets the stomach) may be required to treat both benign and malignant diseases. The most common of the benign diseases is acid reflux caused by a hiatal hernia (defect in the diaphragm) or upside-down stomach (when large portions of the stomach protrude into the chest cavity through the diaphragm). Reflux is a condition in which acid and/or bile from the stomach leak back up into the oesophagus, which occurs in particular when the hole in the diaphragm through which the oesophagus passes becomes larger and small parts of the stomach are pushed up through this hole (this is known as a hiatal hernia). As a result, the valve mechanism between the stomach and oesophagus stops working. One of the symptoms is that the patient feels a strong and rising burning sensation in the chest.
Malignant diseases in this region that require surgery are carcinomas (cancer) of the oesophagus or at the junction where the oesophagus meets the stomach (known as the cardia). Since the treatment and prognosis for these two categories of disease are completely different, the information provided will be divided into two separate sections.
Many patients with acid reflux find that their condition can be controlled satisfactorily with medication (antacids) and so surgery is often not necessary. If this is not the case or if there are complications related to the acid reflux from the stomach, surgery will need to be considered. This also applies if the patient wishes to avoid taking medication for the rest of his or her life. An operation is almost always indicated for patients with an upside-down stomach, partly because of the symptoms and also because of threatening complications.
Heartburn is a typical symptom of acid reflux. It is particularly common when the patient has a hiatal hernia or is overweight and usually occurs after meals or when the patient is lying down. It manifests itself as a burning sensation in the chest just behind the breastbone, hence the name. Additional symptoms may include bad breath, pain when swallowing food and the regurgitation of food from the stomach. Patients also frequently suffer from an unexplained cough, particularly at night or in the morning. This is caused by acid fluid from the oesophagus entering the windpipe and lungs (aspiration). The backflow of stomach acid into the mouth at night may also lead to increased tooth decay. Patients with upside-down stomach suffer from crushing pains in the upper abdomen or chest, especially after eating. There may also be damage to the stomach mucosa (lining), causing bleeding and anaemia.
The suspected diagnosis of reflux is frequently confirmed by symptoms improving when the patient starts taking antacids. To make a definitive diagnosis, however, a gastroenterologist (doctor who specializes in the digestive system) needs to perform a gastroscopy (visual examination of the stomach). This enables the gastroenterologist to see whether a hiatal hernia is present and whether any changes to the mucosa (lining) of the oesophagus have occurred as a result of the acid reflux (severity of the disease). If necessary, a sample of tissue can also be taken. If an operation needs to be planned, it may also be expedient to measure the acidity (pH metry) and pressure (manometry) of the oesophagus. The diagnosis of upside-down stomach can be documented by computerized tomography.
I usually only see patients with these problems after they have been referred to me by a GP or gastroenterologist. The investigations required have then generally already been performed and surgery has been recommended. In my consultation hours, I will then be able to discuss with you in detail the necessity of the operation, the surgical technique planned, prospects for convalescence and the time you will need to take off work as well as potential complications. I will also provide you with information about the anaesthetic, the length of the operation, how long you will need to stay in the clinic, when you will be able to start resuming a normal diet and other important aspects.
If you are otherwise healthy and the investigations required for the anaesthetic (at a minimum, blood test and ECG) have already been carried out beforehand, you can be admitted on the day of your operation (it is important that you have an empty stomach). If you have any relevant related illnesses (increasing the risk of anaesthesia and surgery), however, you will need to be admitted to the clinic the day before the operation. In any event, you will see the anaesthetist before your operation to discuss the anaesthetic. No special preparations are necessary for this operation. You will be able to eat and drink up to six hours before the procedure.
A general anaesthetic is always needed for this procedure, which normally takes around 90 minutes. I can always perform this operation using laparoscopic techniques, in other words using endoscopic or keyhole surgery. Five small incisions need to be made, each measuring between 5 and 10 mm in length. The principle of the operation to treat acid reflux and also upside-down stomach involves first pulling the junction where the oesophagus meets the stomach (some of which has been pushed up into the chest area) back down again. The hole in the diaphragm is then closed with sutures (this is known as crurorrhaphy) or made smaller and finally the stomach wall is wrapped around the oesophagus like a cuff in order to form a “backflow valve” (this procedure is known as fundoplication). This cuff is also held together by sutures and fixed to the diaphragm as well so that it cannot slip back up into the chest area. This eliminates reflux and the symptoms associated with it.
The risk of complications during surgery is very low when it is performed by experienced hands. In theory, it is possible to damage the oesophagus and stomach as well as other organs nearby, but this is extremely rare. Other than moderate swallowing difficulties, problems immediately after the operation are also very rare. In the first few weeks and months after surgery, patients may experience swallowing difficulties, especially when eating too quickly or swallowing pieces of food that are too large and that have not been chewed sufficiently. Some patients may suffer from flatulence in combination with increased passing of wind and possibly more frequent bowel movements. This is caused by the new backflow valve formed at the junction where the oesophagus meets the stomach: the air in the stomach can no longer be “burped out” and so leaves the body “at the other end”. This phenomenon mostly disappears in the medium term.
Since the operation is performed in a minimally invasive way, pain after the procedure is very manageable. You will be able to get up and sit straight away and can receive visitors immediately. The first day after the operation, an X-ray visualization of your oesophagus and stomach will be performed (for which you will need to drink a few drops of contrast dye). You will then be able to start resuming a normal diet. On the first day, you will be given a mainly liquid diet; on the second day after surgery, you will be able to eat soft food. You will have an intravenous drip (supplying fluids, painkillers, etc.) for one or two days after the operation. Antibiotics are only administered during the operation. Wound care is not necessary for the small incisions; they are covered with small waterproof films, so you will be able to have a shower on the second day after surgery. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. You will be able to return home on the third or fourth day after the procedure.
After staying in the clinic for around four days, you will be in good general health when you return home. You will be able to get around independently and cope well with normal everyday life. You can follow a virtually normal diet, although we recommend fairly soft food or food that has at least been well chewed or cut into small pieces for the first two weeks. Normally, you will be signed off work for an additional week or two weeks if you have a physically demanding job. You can resume normal sporting activities two weeks after the procedure. However, you should avoid activities that put a lot of strain on your stomach (such as press-ups, snow shovelling or rowing) for a longer period of time.
If everything goes as planned, you will have no more symptoms after the procedure and will no longer need to take antacids. As a result, no specific follow-up checks are necessary.
The disorder may recur within 10 years of surgery among approx. 5 to 8% of patients; this may mean that a further operation is required.
Depending on its stage and how far it has spread, oesophageal cancer is a disease that should be taken very seriously. The investigations required are time-consuming and treatment is complex. In Switzerland, patients with this disease can only be treated at centres that have been licensed for highly specialized medicine (HSM). Our surgical practice is part of Klinik Hirslanden, which is certified for HSM. All the technical prerequisites and specialists required are available here, ensuring that we are able to investigate and treat this disease at the very highest level. A key factor here is our (surgical) experience, but our empathy and sense of responsibility are also important aspects. I would be happy to see you during my consultation hours to provide advice and help plan your care, and will be with you every step of the way on this difficult treatment journey.
In order to plan their treatment, the situation of patients suffering from oesophageal cancer is discussed at our clinic during an interdisciplinary Tumour Board Meeting (which takes place weekly in competence centres for tumour treatment) in the presence of all necessary specialists. The next treatment steps are subsequently proposed at these meetings. A surgeon, oncologist, radiotherapist, gastroenterologist, pathologist and possibly other specialists are present. These specialists must decide whether to recommend an operation or preliminary treatment (with chemotherapy, i.e. with medication, and/or radiotherapy, i.e. with radiation) before the procedure as the first step. Provided there are prospects of recovery (curative concept), surgical removal of the tumour is always at the heart of the treatment.
Difficulties with swallowing food are a typical symptom: the food becomes stuck and causes a dull pain deep in the chest. Frequently, however, it simply feels like acid reflux, which gets better when antacids are taken. Relying on it being “just acid reflux” may be fatal, however. A gastroscopy (visual examination of the stomach) is therefore always recommended if a patient is experiencing these symptoms, especially if the symptoms are new. In individual cases, the symptoms may also be accompanied by worsening health and weight loss, particularly if the patient is only able to eat a liquid diet.
A visual examination of the oesophagus and stomach by the gastroenterologist is central to the investigation. This enables the tumour to be identified and at the same time confirmed microscopically by the pathologist on the basis of a tissue sample. If this is the case, the gastroenterologist (doctor who specializes in the digestive system) will also perform an endosonography, i.e. an internal ultrasound. This involves inserting a small ultrasound probe into the oesophagus using a gastroscope (an instrument used to visually inspect the interior of the stomach) and then examining the part of the oesophagus affected by the tumour, with the probe in direct contact with this part. The endosonography enables the gastroenterologist to accurately determine how far the tumour in the mucosa (lining) has grown into the deeper layers of the oesophagus or even beyond. The examination also allows the gastroenterologist to check whether there are any enlarged lymph nodes near the tumour that may raise suspicions of metastases. In addition, a computerized tomography scan is always required. If necessary, the diagnostic tests may also include a PET/CT scan, a combination of computerized tomography and scintigraphy. This enables the presence of distant metastases to be detected or ruled out. If any doubts remain before treatment is planned, a diagnostic laparoscopy (visual inspection of the abdominal cavity under anaesthetic) may be performed in order to rule out or detect tumours in the peritoneum (the membrane that lines the abdominal cavity) or liver.
As soon as the results of all investigations are available, your current situation is discussed at the interdisciplinary Tumour Board Meeting and I will then see you during my consultation hours to explain the proposed treatment plan to you. If the tumour is already relatively large (if it has invaded the entire wall of the oesophagus) and/or lymph node metastases are suspected, we will recommend that you undergo pretreatment with chemotherapy or a combination of chemotherapy and radiotherapy before surgery. The operation will then take place around two to three months later. We will discuss your treatment plan, in particular the operation planned, risk of complications, therapy and care during your stay in the clinic, possible complications after the procedure and the convalescence period. We will also talk about the option of additional chemotherapy after the operation and what kind of long-term follow-up care you will receive.
The type of operation selected depends mainly on the location of the tumour.
Tumours in the middle and lower third of the oesophagus: removal of part of the middle and lower oesophagus with
opening of the abdominal and chest cavity (abdominal and separate thoracic access point); reconstruction of the oesophagus by shaping the stomach into a tube, pulling it up and connecting it to the remainder of the oesophagus in the chest cavity
Tumours in the middle and upper third of the oesophagus: removal of almost the entire oesophagus with
Tumours in the lower third of the oesophagus: removal of the lower oesophagus with
Tumours in the lower third of the oesophagus which have spread to the junction between the oesophagus and stomach: removal of the lower oesophagus and entire stomach with
If circumstances permit, the part of the operation in the abdomen can also be performed laparoscopically (via keyhole surgery).
Since these operations are major procedures that can only be performed under general anaesthetic, you will need to be admitted the day before the operation. Other than a high enema, no specific preparations are necessary. You will be given a light meal in the evening. The anaesthetist will discuss matters relating to the anaesthetic and post-operative pain treatment with you. I will also see you on the day that you are admitted and we will be able to discuss any final questions about the procedure. You must not eat or drink anything for at least six hours before the operation.
A general anaesthetic is always required for all the oesophageal cancer procedures described, which last between four and six hours.
This is the standard operation for tumours in the middle and lower third of the oesophagus. The procedure begins with the surgeon making an incision in the abdomen to expose the stomach, which is then divided into two so that the junction where the oesophagus meets the stomach remains attached to the oesophagus and the rest of the stomach is shaped into a tube. The chest then needs to be opened on the right side between the ribs. In the chest cavity, the oesophagus is then released as far as necessary and severed above the tumour, leaving a safety margin. The section consisting of oesophagus and junction between oesophagus and stomach (with the tumor) can then be removed. The stomach tube is pulled up into the chest cavity through the natural opening in the diaphragm and connected there to the healthy oesophagus.
The operation is substantially performed as described above. The difference is that the chest area is not opened; instead, an additional access point is created in the neck and the stomach tube is pulled up and connected to the oesophagus there.
The operation is substantially performed as described above. The difference is that the chest area is not opened and the connection between the oesophagus and stomach tube is made exclusively from the abdomen, if necessary through an enlarged opening in the diaphragm.
The operation is substantially performed as described above. The difference is that the chest area is not opened. Moreover, the stomach is completely removed and is reconstructed using a loop of small intestine. The operation is performed exclusively in the abdomen.
The most dangerous complication is that the new connection created between the oesophagus and stomach tube (or loop of small intestine) does not provide immediate airtight and watertight closure. As a result, contents of the gastrointestinal tract (food, fluid from the small intestine) may leak into a cavity of the body (chest cavity or abdomen) and cause serious infectious complications. The risk is approx. 3 to 5%. If this complication occurs, action must be taken as a matter of urgency; an emergency operation is sometimes necessary. Otherwise, the usual range of complications after major surgery may occur, such as post-operative bleeding, pneumonia, infection of the bladder or wound infection. The overall complication rate for this procedure is 15 to 20%. Acid reflux is generally a long-term side effect of this operation, but it can be well controlled with antacids.
Nach der Operation verbringen Sie mindestens 1 bis 2 Tage auf der Intensivstation. Manchmal istYou will spend at least one to two days in intensive care after surgery. Some patients may need to be on a ventilator in the first night. All the necessary painkillers will be administered. If your chest cavity was opened, you will need to have a chest drain for the first few days after surgery, which will significantly restrict your mobility. However, you will be able to sit in an armchair with help. For the first few days you will only be given liquids – a small amount initially, which will then be increased. Artificial feeding via an intravenous drip is necessary at this stage. Around four days after the operation, you will be able to start transitioning to a normal diet. Once the first five days are over, you will start making more rapid progress; the chest drain can then be removed and subsequently, if all goes well, the intravenous drip. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. Overall, you can expect to stay in the clinic for 14 days.
Dennoch können Sie sich mit Hilfe in den Lehnstuhl setzen. In den ersten Tagen ist nur die Aufnahme von Flüssigkeiten möglich, zunächst in geringer Menge, dann gesteigert. In dieser Phase ist eine künstliche Ernährung über die Infusion nötig. Der wirkliche Nahrungsaufbau beginnt etwa ab dem 4. postoperativen Tag.
After major surgery of this kind, we recommend that most patients – particularly those who live alone – go away to convalesce after they have been released from the clinic. You may feel very tired and weak at first. Light sporting activities can be resumed after about one month. You are likely to be unable to work for around two months, possibly longer if follow-up treatment is required. However, you will be able to achieve a virtually normal quality of life in the medium term.
As soon as the tissue sample has been examined under the microscope, the histopathological tumour stage can be determined. The situation is then discussed at the interdisciplinary Tumour Board Meeting and additional chemotherapy (treatment with medication) may be recommended in order to improve the prognosis. This is an outpatient procedure, usually lasts around three months and may be accompanied by (significant) side effects. Follow-up checks generally depend on the patient’s condition. Very frequent and time-consuming checks-up are not absolutely necessary since treatment options are limited if the disease returns.
In recent years the use of pretreatment (chemotherapy and radiotherapy) has improved the prognosis for this disease, which was previously very poor. Nevertheless, oesophageal cancer has a very high recurrence rate (approx. 70% within three years). It goes without saying that the prognosis is best if the cancer is detected at an early stage; it is therefore very important to have any new symptoms (as described above) investigated as soon as possible.
The gallbladder and liver are two organs that are closely linked, both anatomically and in terms of their function. However, diseases and operations on these two organs are completely different. The vast majority of procedures on the gallbladder are related to gallstones, while most operations on the liver are performed to remove tumours. It therefore makes sense to discuss the two organs in separate sections.
Gallstones in the gallbladder and occasionally also in the bile ducts are very common. As long as they are not causing any problems, they often remain undetected. They may lead to complications, however – typically colic pain or inflammation of the gallbladder, for example. Small stones may also pass down via the bile ducts and then become stuck where the common bile duct and pancreatic duct open into the duodenum. This causes pain and possibly also jaundice; it may also result in bile duct inflammation or, at worst, pancreatitis. Whenever gallstones cause complications, gallbladder surgery is recommended; it is generally planned in advance but may sometimes need to be performed as an emergency.
When a gallstone is stuck in the bile duct, an experienced gastroenterologist (doctor who specializes in the digestive system) needs to first perform a gastroscopy (visual examination of the stomach) with ERCP (endoscopic retrograde cholangiopancreatography) in which the endoscope is inserted down to the duodenum, where a fine probe is pushed through the natural opening of the common bile duct and into the bile duct. The stone is then captured using a “basket”.
In the case of biliary colic, severe or very severe burning pain in the upper abdomen starts suddenly, usually on the right side. A typical feature of colic is that the patient is usually completely free of pain for periods in between the intense attacks. In the case of inflammation of the gallbladder, increasing pain on the right side of the upper abdomen usually starts within one to three days; it is less intense than colic but there are no breaks from the pain. It may be accompanied by fever, nausea and a feeling of unwellness.
In the case of a stone in the bile duct, pain in the upper abdomen – which may be colic-like – starts within hours. It is sometimes accompanied by jaundice, the first sign of which is that the whites of the eyes (and later the skin) become yellow; the patient’s urine may be brown.
In the case of pancreatitis, increasing pain in the upper abdomen occurs within one to two days and sometimes radiates to the sides and round to the back, like a belt. It may be accompanied by fever, nausea, a severe feeling of unwellness and also a serious deterioration in the patient’s general health.
Ultrasound is the best method for diagnosing gallstones. It is quick, cost-effective and accurate, but needs to be performed by experienced hands. In addition, a blood test is always required, in particular to check for signs of inflammation and evaluate the function of the liver and pancreas. If both examinations indicate that bile flow is blocked (as a result of a gallstone in the common bile duct), a gastroscopy (visual examination of the stomach) must be performed in which the endoscope is pushed down to the duodenum and enters the common bile duct to remove the stone (known as ERCP; see below). In rare cases, MRI (magnetic resonance imaging) can be performed in order to produce further images of the bile ducts. In cases of pancreatitis, computerized tomography of the abdomen is often indicated.
The investigations are usually carried out by your GP or gastroenterologist, and I will then see you during my consultation hours once a diagnosis has been made. We will then discuss the reason for the operation, the type of surgical procedure, the necessity of an anaesthetic, possible complications and also aspects related to convalescence and the length of time you will need to take off work. If you are admitted to the clinic as an emergency, we will perform the investigations and discuss your treatment there.
Stones in the gallbladder
Stones in the bile ducts
For operations on the gallbladder, you do not need to be admitted to the clinic until the day of your operation – depending on your general state of health. In this case, however, the investigations required for the anaesthetic (ECG, blood test, chest X-ray) will need to be done beforehand by your GP. If there are anaesthetic risks, we recommend that patients are admitted the day before surgery. Shortly after you have been admitted, the anaesthetist will discuss with you the anaesthetic method that will be used. Depending on the type of anaesthetic, we will inform you in good time about how long you can still eat and drink before the procedure.
Most gallstone operations nowadays are performed using the laparoscopic technique (keyhole surgery). This method, also known as abdominal endoscopy, involves inserting optical and surgical instruments into the abdominal cavity through small incisions. The surgeon looks at a TV monitor during the procedure since he or she can only see into the abdomen via a video camera. This saves you from having a large incision, pain and an unattractive scar. You will need to have a general anaesthetic, however.
Virtually all gallbladder removals nowadays are performed using the laparoscopic technique. The procedure involves locating the gallbladder and then severing the short gallbladder duct and the small gallbladder artery between clips. The gallbladder is then detached from its contact surface with the liver and removed – complete with stones – from the abdomen via the incision in the navel. After the instruments have been removed, the small incisions in the skin are closed with an intracutaneous suture (the thread lies beneath the skin, where it cannot be seen). The operation takes between 40 and 60 minutes.
Surgery always involves removing the entire gallbladder. If only the stones were to be removed, new stones would be certain to form. Removing the gallbladder does not lead to any loss of function: bile continues to be produced in the liver and flows into the intestine. Although there is no longer anywhere to store bile that can be released when more bile is needed (fatty food), this does not seem to be very important.
This is a variant of the laparoscopic technique in which, instead of four small incisions (5 to 10 mm), only one incision of approx. 20 mm in length is made in the navel. This technique is only suitable for selected situations (slim patients, no inflammation of the gallbladder).
This operation, which involves a (relatively large) incision in the abdomen, does not need to be performed very often – only if there is exceptionally severe inflammation of the gallbladder, for example, or in the rare case of gallbladder tumours.
These procedures are now rare since most problems involving gallstones in the bile ducts can be solved by a gastroenterologist using ERCP (see above).
The complication rate for laparoscopic gallbladder removal is very low; the overall rate, covering all possible complications, is approx. 2%. The most serious complication is injury of the common bile duct; the risk is a few tenths of a percent. The same applies to potential damage to other organs during the procedure. As with any operation, there is also a possibility of a haematoma or wound infection. Finally, the risk of thrombosis and pulmonary embolisms should be mentioned, but this risk is also very low.
After the operation you will spend several hours in the recovery room before being taken to your room. Since the operation is performed in a minimally invasive way and you will routinely be given painkillers, you will experience very little pain. You will be able to get up, walk around and have something to drink a few hours after the procedure, and can have something light to eat in the evening. As the small incisions in your skin are closed with an intracutaneous suture (the thread lies beneath the skin, where it cannot be seen) and covered with films, you do not need to have any dressings changed or stitches removed. This also means that you can shower the day after your operation. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. You can generally return home on the second day after the operation. If you have had open surgery with an incision in your abdomen, everything will take a few days longer.
As a rule, you will feel very well when you return home. You do not need to follow a special diet or to avoid physical activity. Nevertheless, we recommend you take a few days (normally one week) off work or two weeks if you have a physically demanding job. You can subsequently resume any kind of sport without restrictions. If you have had open surgery with an incision in your abdomen, this will understandably take two to three weeks longer.
Neither additional follow-up treatment nor follow-up checks are required after standard gallbladder removal for common indications. If there have been complications associated with gallstone problems, such as inflammation or suppuration of the gallbladder or pancreatitis, follow-up treatment and checks may be necessary depending on the individual situation. This applies in particular to patients with stones in their bile ducts. As described above, an ERCP (see above) is primarily performed here. Follow-up treatment then always involves planned gallbladder removal, which is also necessary to prevent the problem from recurring.
Once the gallbladder containing the stones has been removed, the problem is normally definitively solved for ever. The prognosis is excellent. Relapses are virtually non-existent. The situation may be slightly different if stones in the bile duct have caused pancreatitis. If this illness is severe (which is fortunately a rare occurrence), the patient’s life may be in immediate danger.
In Switzerland, operations on the liver can only be performed at centres that have been licensed for highly specialized medicine (HSM). Our surgical practice is part of Klinik Hirslanden, which is certified for HSM. All the technical prerequisites and specialists required are available here, ensuring that we are able to investigate and treat diseases of the liver at the very highest level. A key factor here is our (surgical) experience, but our empathy and sense of responsibility are also important aspects. I would be happy to see you during my consultation hours to provide advice and help plan your care, and will be with you every step of the way on this difficult treatment journey.
The most common reason for an operation on the liver is a malignant tumour. This may be either a tumour that started in the liver itself (primary tumour), e.g. a malignant tumour of the liver tissue (hepatocellular carcinoma) or bile ducts (cholangiocellular carcinoma), or metastases (secondary cancer cells from malignant tumours in other organs) may be present, most frequently metastases of colon, breast and kidney tumours, for example.
Whether a patient will benefit from surgery is a decision that must always be made on a case-by-case basis by an experienced liver surgeon during an interdisciplinary Tumour Board Meeting. Cases of this kind are discussed at these weekly meetings, which are held in competence centres for tumour treatment in the presence of all necessary specialists. The next treatment steps are subsequently proposed. A surgeon, oncologist, radiotherapist, gastroenterologist, pathologist and possibly other specialists are present. If a patient has liver metastases from a malignant colon tumour, for example, it is generally advisable to operate, whereas surgery is usually of no benefit if the patient has metastases from a malignant pancreatic, gastric, oesophageal or prostate tumour. Finally, surgical treatment is required for benign tumours and also liver cysts or abscesses that are either congenital or caused by infectious diseases. And in rare cases, congenital abnormalities of the liver vessels or bile ducts may also necessitate an operation.
Liver tumours and metastases do not cause any symptoms for a long time. Primary liver tumours are usually detected when patients are investigated for unexplained upper abdominal complaints or possibly jaundice if an ultrasound or computerized tomography scan is performed to establish the cause. Liver metastases are mainly detected during routine follow-up checks after treatment for another tumour. For example, regular ultrasound and computerized tomography examinations are carried out according to a fixed schedule after surgery to remove a colon tumour.
A large proportion of tumours in the liver can be detected by ultrasound. To confirm the diagnosis, this is usually followed by a computerized tomography scan and in some cases MRI (magnetic resonance imaging) in order to plan the operation. A PET/CT scan is also required in order to plan treatment, especially if surgery on the liver is planned. This combination of computerized tomography and scintigraphy enables the presence of tumours and also distant metastases to be very accurately detected or ruled out. If other metastases are present outside the liver (in the lung or bones, for example), curative treatment (aiming to cure the patient) is often no longer possible; this means that liver surgery can no longer help.
A sample of tissue (liver biopsy) will occasionally need to be taken to aid decision-making; this can be done as an outpatient procedure under local anaesthetic using a fine needle with ultrasound or CT monitoring. Finally, it is important to take a blood test to check the liver function. It should be substantially normal so that the part of the liver that remains after the operation (which may only be 1/3) can fulfil its vital functions.
I usually see patients with these diseases after they have been referred to me by a GP, gastroenterologist or oncologist. The investigations required have then generally been performed and the diagnosis has been made. If you have a malignant tumour, the treatment plan is first discussed at one of the interdisciplinary Tumour Board Meetings (see above) and if surgery on the liver is proposed at the meeting as the most suitable next treatment step, I will see you during my consultation hours. I will then discuss with you the treatment plan, in particular the operation planned, how long it will take, the necessity of the anaesthetic, the risk of complications and also therapy and care during your stay in the clinic. We will provide you with information about resuming a normal diet after the operation, mobility, wound care, how long you will stay in the clinic and the convalescence period. We will also discuss the option of additional chemotherapy after the operation and what kind of long-term follow-up care you will receive.
Operations for liver tumours or metastases
Operations for liver cysts
Operation on the bile ducts of the liver
Since these operations are (usually) major procedures that can only be performed under general anaesthetic, you will need to be admitted the day before the operation. Other than a high enema, no specific preparations are necessary. You will be given a light meal in the evening. The anaesthetist will discuss matters relating to the anaesthetic and post-operative pain treatment with you. I will also see you on the day that you are admitted and we will be able to discuss any final questions about the procedure. You must not eat or drink anything for at least six hours before the operation.
How long a liver operation takes and the technique used depend to a large extent on the diagnosis and the complexity of the procedure.
Conventional liver resection (removal of the right or left lobe of the liver) involves selectively exposing and severing the right (or left) branch of the portal vein, the right (or left) hepatic artery and the right (or left) common bile duct where they enter the liver. The half of the liver that is no longer supplied with blood then turns dark in colour and the liver tissue can be severed along the border to the tissue that has a normal blood supply with little loss of blood. To do so, we use an ultrasound probe that cuts through the tissue but leaves larger vessels or bile ducts intact so that they can be sealed securely and tightly with clips or sutures. To achieve thermal haemostasis at the surface that has been cut, instruments with monopolar or bipolar current or an ignited beam of argon gas may be used.
Staplers are increasingly used nowadays to sever the tissue. These scissor-like devices can grasp and cut through portions of liver tissue, while at the same time the vessels and bile ducts can be sealed where they have been cut using a large number of small titanium staples. These new techniques have made liver surgery faster and safer, with the result that removing half of the liver now only takes a maximum of two to three hours and the patient does not usually need to receive any donor blood.
In some cases an ultrasound scan is needed during the operation and is performed directly on the liver. This enables deep metastases that can be neither seen nor felt to be identified and included in the resection.
If necessary, intraoperative frozen section analysis – immediate examination of tissue under the microscope during the operation – of the tissue obtained can also be performed in order to check that the tumour has been completely removed.
If only a small part of the liver is removed, the surgical techniques used are the same as described above but without prior selective severing of the major blood vessels and common bile duct. In situations that are not technically difficult (small lump, located on the surface and visible) and in particular if the tumour is benign, the procedure can sometimes be performed laparoscopically (in a minimally invasive way, also known as keyhole surgery).
Congenital liver cysts only require surgery if they are so large that they press against other organs and cause discomfort. The procedure, which is always performed under anaesthetic, is very straightforward and takes one hour at most. It involves cutting a large “window” out of the accessible surface of the cyst using the laparoscopic technique (keyhole surgery). If the liver cysts were caused by dog tapeworm, however, the operation will involve removing the entire cyst plus a border of liver tissue (approx. 5 mm). This procedure, which takes around two hours, must therefore be performed as open surgery under anaesthetic via an abdominal incision using some of the same resection techniques as those employed in conventional liver surgery.
This mainly involves removing part of the main bile duct due to a tumour or malformation. The operation, which takes around two hours, must be performed via an incision in the abdomen; an anaesthetic is unavoidable. To restore bile flow, part of the small intestine must be pulled up to the bile duct in the liver and joined to it with a suture.
Although modern techniques for cutting through liver tissue make the procedure much safer nowadays, bleeding may still occur either immediately after the operation (within 72 hours) or during the procedure and may, in rare cases, necessitate a second operation and/or the transfusion of donor blood. Bile leakage, which may occur in the first few days after surgery, is also rare but very typical: bile ducts severed during the resection are no longer watertight and bile fluid leaks from the cut surface. In the event of this happening, the bile must be drained from the abdomen since it can otherwise lead to inflammation and form an abscess. If the drainage is effective, healing is usually achieved without the need for a further operation. Finally, the liver may be unable to function fully due to the loss of too much liver tissue. If the liver was previously healthy apart from the tumour, this risk is very small. However, if cirrhosis is present or an excess of fat has built up and if half or more of the liver has been removed, the risk increases significantly. In moderate cases, jaundice occurs for several days after the operation; in serious cases, temporary impairment of the senses may occur and in very rare cases the patient’s life may be at risk.
After the operation you will spend at least one night in the intensive care unit, sometimes one to two days. You will be given the necessary medication to treat any pain. Even after major liver surgery, you will be able to move about and have something to drink straight away and will soon be able to eat light food. Artificial feeding is not usually necessary. Initially, you will need to have blood taken every day to check your liver function. If all goes well, the intravenous drip (supplying fluids, painkillers, etc.) will be removed after around five days; the same applies to the drain in the abdominal cavity if there are no signs of bile leakage. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. Depending on the extent of the surgery and any possible complications, you will stay in the clinic for around 10 days for conventional liver tumour surgery; the length of stay will be shorter for laparoscopic liver cyst surgery.
If you have had a major liver operation to remove a tumour, we recommend that you go away to convalesce or to a health resort after you have been discharged from the clinic, particularly if you live alone. After a procedure of this kind, you may feel tired and weak at first. Light sporting activities can be resumed after one month at the earliest. You are likely to be unable to work for around two months, possibly longer if follow-up treatment is required. If you have had a more minor procedure and in particular if you have had surgery to treat a benign disease, the recovery time is much shorter, a stay at a health resort is not necessary and you may be able to return to work after one week. Whatever liver surgery you have had, you will be able to achieve a virtually normal quality of life in the short or medium term.
After surgery to remove a liver tumour, the situation (taking into account the results of the examination under the microscope) is discussed at the interdisciplinary Tumour Board Meeting and additional chemotherapy (treatment with medication) may be recommended in order to improve the prognosis. This is an outpatient procedure, usually lasts around three months and may be accompanied by (significant) side effects. In addition, regular check-ups with a specialist – usually an oncologist, who specializes in the treatment of (malignant) tumours with chemotherapy – are then always required in accordance with international guidelines. If the operation was performed to treat a cyst caused by dog tapeworm, antiparasitic follow-up treatment (antibiotics) is necessary; in the case of congenital cysts, no follow-up treatment or checks are required.
Liver tumours or metastases are diseases that must be taken seriously and have an unfavourable prognosis. Operations on the liver are complex and are only performed for diagnoses (particularly in the case of metastases) and on patients if the prognosis can be improved as a result. Nevertheless, only some of the patients will really benefit from surgery. Depending on your current situation and the illness behind it, the different aspects of the prognosis must be discussed on a case-by-case basis and I would be happy to do so with you. If you have one of the benign diseases mentioned above, the prognosis is generally excellent.
Operations on the pancreas are required to treat either inflammation (pancreatitis) or tumours. The background, course, surgery and prognosis for these two disease forms are very different and so they will be described in two sections below.
In Switzerland, operations on the pancreas can only be performed at centres that have been licensed for highly specialized medicine (HSM). Our surgical practice is part of Klinik Hirslanden, which is certified for HSM. All the technical prerequisites and specialists required are available here, ensuring that we are able to offer the entire range of procedures on the pancreas at the very highest level. A key factor here is (surgical) experience, but empathy and sense of responsibility are also important aspects. I would be happy to see you during my consultation hours to provide advice and help plan your care, and will be with you every step of the way on this difficult treatment journey.
(Acute) pancreatitis is caused by gallstones in 40% of cases and by chronic (excess) alcohol consumption in 30% of cases. Small gallstones may pass from the gallbladder into the bile ducts and then become stuck where the bile duct and pancreatic duct open into the duodenum. This can lead to a congestion of pancreatic juice in the duct and consequently cause inflammation of the pancreas. Long-term excessive alcohol consumption can result in both acute and in particular chronic pancreatitis, and is responsible for 80 to 90% of cases of the latter.
Treatment for acute or chronic pancreatitis only entails surgery if complications of the disease occur. In most cases of acute pancreatitis, no operation is necessary. If the disease runs a very severe course – which is fortunately rare – it may lead to the pancreas starting to “digest” itself, however. Due to the partial destruction of the organ that then occurs, the pancreatic juice may enter the pancreatic tissue and neighbouring fatty tissue with the digestive enzymes and attack (“digest”) this tissue.
Enzymes are proteins that can control biochemical reactions. The enzymes in the pancreas play a key role in digestion: amylase breaks down carbohydrates, lipase breaks down fats and trypsin breaks down proteins to make them digestible. The dead tissue that has been digested in this way can be infected and thus lead to abscesses, peritonitis or bleeding. An emergency operation is then required. In the case of chronic pancreatitis, inflammation that has usually lasted for several years leads to shrinkage and scarring of the pancreas with typical associated secondary conditions, such as cysts in the pancreas or narrowing of the pancreatic duct (and sometimes of the bile duct). Since this narrowing can intensify the blockage in the pancreas and prevent healing, an operation must be performed. In addition, the chronic pain experienced by the patient often makes surgery necessary.
The main symptom of acute pancreatitis is upper abdominal pain that develops suddenly and frequently radiates round to the back. Patients usually feel very unwell and frequently experience nausea; vomiting and fever are not uncommon. Rapidly worsening pain and a deterioration of their general condition lead patients to visit their doctor as an emergency or attend the emergency department of a hospital.
Patients with chronic pancreatitis have usually had fluctuating, sometimes severe upper abdominal pain for a long time. They often take painkillers constantly or try to combat the pain by consuming more alcohol (which makes the disease even worse). Chronic inflammation of the pancreas can cause the organ to lose its ability to function. A lack of digestive enzymes can lead to repeated episodes of diarrhoea, while the lack of insulin can result in diabetes.
Computerized tomography is the most important investigation here since it enables the diagnosis to be made in most cases and often the decision to operate as well. An ERCP (endoscopic retrograde cholangiopancreatography) is sometimes required too; this is an endoscopy or visual examination of the stomach in which the gastroenterologist (doctor who specializes in the digestive system) pushes an endoscope down to the duodenum and exit of the common bile duct. It enables narrowings in the pancreatic or bile duct to be shown more precisely (and possibly opened up). In addition, a blood test to determine the pancreatic enzymes (amylase, lipase), signs of inflammation and liver values must always be carried out.
I usually see patients with acute pancreatitis in conjunction with other specialists in the emergency unit. We then discuss the diagnosis and measures required (immediate surgery is not normally necessary). I generally see patients with chronic pancreatitis during my consultation hours after they have been referred to me by a GP or gastroenterologist. The investigations required have then usually already been performed and the diagnosis or suspected diagnosis has been made. I will then discuss the treatment plan with you, in particular the operation planned, how long it will take, the necessity of the anaesthetic, the risk of complications and also therapy and care while you are in the clinic. We will provide you with information about resuming a normal diet after the operation, mobility, wound care, how long you will stay in the clinic and the length of the convalescence period.
Acute pancreatitis
Chronic pancreatitis
Since these operations are (usually) fairly major procedures that can only be performed under general anaesthetic, you will need to be admitted the day before the operation. Other than a high enema, no specific preparations are necessary. You will be given, at most, a light meal in the evening. The anaesthetist will discuss matters relating to the anaesthetic and post-operative pain treatment with you. I will also see you on the day that you are admitted and we will be able to discuss any final questions about the procedure. You must not eat or drink anything for at least six hours before the operation. The process will be slightly different if you are admitted as an emergency.
Operations for pancreatitis must always be performed under general anaesthetic and through an incision in the abdomen (usually a transverse opening in the upper abdomen). The laparoscopic technique (minimally invasive abdominal endoscopy) is not a feasible option here.
If acute pancreatitis runs a severe course (the patient will usually have been in the clinic for weeks), the extensive destruction (necrosis) of pancreatic tissue and tissue in the immediate vicinity may occur. Consequences include infections, abscesses and, at worst, internal bleeding. If the patient’s condition worsens despite all possible measures being taken, e.g. antibiotics and possibly punctures, an operation will need to be performed. This entails opening the abdominal cavity, removing the dead tissue – which is usually infected – and any abscesses present, and stopping bleeding. If the disease was caused by gallstones, the gallbladder will also need to be removed. The operation takes around two to three hours. It is not uncommon for two to three follow-up operations to be needed within a short space of time in order to “clean up” everything completely. The seriously ill patients stay in the intensive care unit during this stage and are artificially ventilated; their condition can sometimes be critical. In selected – less serious – cases, defined tissue necrosis (locally limited dead tissue) can now also be removed by a gastroenterologist via a gastroscopy in which the source of the disease is reached through the stomach wall.
This operation is recommended if chronic inflammation has led to extensive and painful scarring of the pancreas head with narrowing of the pancreatic duct and (usually also of the) bile duct. The head of the pancreas is removed – along with the narrowed sections of the pancreatic and bile ducts – but the duodenum is preserved. The resulting “defect” in the pancreas is covered by a loop of small intestine that is sutured on so that the secretions from the bile and pancreatic ducts can drain properly. The procedure is concluded with the gallbladder also being removed and takes three to four hours.
If a (relatively large) cyst has developed in or on the pancreas – usually connected to the pancreatic duct – the surgical removal of the cyst and drainage into the small intestine (cystojejunostomy) are required since the patient otherwise risks developing complications (inflammation may persist, bleeding in rare cases). This involves opening the cyst and removing it as far as possible without removing any pancreatic tissue. A loop of small intestine must then be sutured onto the remaining “crater” on the pancreas so that the pancreatic juice can drain properly. The operation, which takes around three hours, usually also includes the removal of the gallbladder.
The splanchnic nerves are part of the autonomic nervous system and transmit pain from the region of the abdominal organs. If a patient is suffering from chronic pain caused by a disease of the pancreas – which cannot be treated satisfactorily with medication – the pain can be reduced or even eliminated completely by cutting through these nerves. The procedure can be performed using a minimally invasive thoracoscopic approach (keyhole surgery), but requires a general anaesthetic. Instruments including a video camera are inserted into the chest cavity through small incisions in the chest wall; the critical small nerve branches are identified and then divided. The operation, which takes around one hour, must be performed on both sides; no other losses of function result from this procedure.
The removal of infected tissue necrosis (dead tissue) around the pancreas that is required – albeit rarely – in the case of acute pancreatitis is associated with a relatively wide range of complications due to the difficult circumstances (infection). It is frequently not possible to “clean up” everything sufficiently with just one operation, with the result that follow-up operations are needed. Neighbouring organs (intestine) may be damaged during these operations or post-operative bleeding may occasionally occur.
Operations to treat chronic pancreatitis involve joining the cut edge of the pancreas or cyst to the small intestine by sutures. If this join starts to leak (within the first five to seven days), pancreatic juice – with its digestive enzymes – may enter the abdominal cavity. This rare complication (2 to 3%) can cause serious problems such as infection or bleeding.
After pancreas head resection to treat chronic pancreatitis, you will spend at least one night – sometimes one to two days – in the intensive care unit. All the necessary painkillers will be administered. The nursing staff will help you to move around – at least into an armchair – straight away. For the first few days you will only be able to take liquids – a small amount initially, which will then be increased. Artificial feeding via an intravenous drip is necessary at this stage. Around four days after the operation, you will be able to start transitioning to a normal diet. You will initially need to have blood taken every day to check your organ functions and diagnose any infection at an early stage. If all goes well, the intravenous drip can be removed after around four to five days as can the drain in the abdominal cavity if there are no signs of leakage.
If you have had an operation for a pancreatic cyst, the recovery stage is generally shorter and less complex. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. Depending on the extent of the surgery and any possible complications, you will stay in the clinic for around 12 days for pancreas head resection; the length of stay will generally be shorter for a cyst operation. For patients who have had surgery to treat severe acute pancreatitis, post-operative progress can vary significantly; in most cases, however, these patients spend days or weeks in the intensive care unit or several weeks in the clinic.
After major surgery on the pancreas or a severe case of acute pancreatitis, we recommend that most patients – especially those who live alone – go away to convalesce after they have been discharged from the clinic. You may feel very tired and weak at first. Light sporting activities can be resumed after around one month. You are likely to be unable to work for around two months, possibly longer. The recovery period is shorter after more minor operations on the pancreas. The quality of life after surgery depends on whether you still have chronic pain and/or insufficient pancreatic function (exocrine or endocrine insufficiency). If not enough digestive enzymes are produced due to the loss of pancreatic tissue, proteins, carbohydrates and fats in the diet may not be broken down sufficiently (exocrine insufficiency).
This results in inadequate nutrition with the loss of undigested nutrients in the stool, recognizable for example by diarrhoea and possibly also weight loss. The diagnosis can be confirmed by a stool analysis. Treatment is straightforward and consists of an enzyme replacement in the form of tablets. The loss of pancreatic tissue due to an operation or chronic inflammation may also lead to insufficient insulin production (endocrine insufficiency). The result is diabetes, which must be treated with insulin injections and monitored by patients measuring their blood sugar several times a day. Generally speaking, however, a normal quality of life can be achieved in the medium term.
With these diseases, special follow-up care is usually only necessary if long-term treatment is required as a consequence of insufficient pancreatic function (see above). Likewise, patients who became ill as a result of chronic alcohol consumption will require further monitoring, particularly in order to help them achieve the vital goal of abstinence (giving up alcohol).
The loss of pancreatic tissue caused by chronic inflammation or by surgery to treat severe cases of acute pancreatitis can later lead to a loss of function. Insufficient enzymes mean poor digestion (recognizable by diarrhoea, for example), which can be easily compensated by enzyme tablets. A lack of insulin is rather more serious; this causes diabetes, which may need to be treated with insulin injections. If chronic pancreatitis is caused by alcohol, abstinence is a key factor in the prognosis. Acute pancreatitis is frequently caused by gallstones and can be cured by treating the gallstones and thus eliminating the cause.
Malignant tumours of the pancreas (pancreatic carcinomas) are feared for good reasons, surgical treatment is complex (with potentially serious complications) and even today the prognosis is unfavourable. Once this disease – which must be taken very seriously – has been diagnosed, it must be assessed and treated at an appropriate interdisciplinary tumour centre; at our clinic, we are able to provide this service.
Once a tumour in the pancreas has been diagnosed, the aim should be to surgically remove it. The decision as to whether an operation is possible and advisable must always be made on a case-by-case basis by an experienced abdominal (visceral) surgeon during an interdisciplinary Tumour Board Meeting. Cases of this kind are discussed at these weekly meetings, which are held in competence centres for tumour treatment in the presence of all necessary specialists. The next treatment steps are subsequently proposed. A surgeon, oncologist, radiologist, radiotherapist, gastroenterologist, pathologist and possibly other specialists are present.
The symptoms of pancreatic tumours depend on their location in the pancreas and at least to some extent on the type of tumour (benign or malignant). In most cases, patients with malignant tumours in the head of the pancreas suddenly develop painless jaundice. If the tumour is located in the tail of the pancreas, the patient will suffer very few symptoms for a long time before he or she finally starts to feel unwell and to experience upper abdominal and possibly back pain. Benign tumours, which are very rare, are often only detected incidentally during investigations (ultrasound or computerized tomography) that are being performed for another reason. Certain tumours form hormones and thus cause specific symptoms according to the particular hormone function. Regular severe hypoglycaemia (low blood sugar) can occur, for example.
If a patient is experiencing the symptoms described or if a tumour is suspected – on the basis of an ultrasound scan, for example – a computerized tomography scan is first performed. This is the most important investigation since it enables the diagnosis to be made in most cases and often the decision to operate as well. If jaundice has appeared, an ERCP (endoscopic retrograde cholangiopancreatography) is required; this is an endoscopy or visual examination of the stomach in which the gastroenterologist (doctor who specializes in the digestive system) pushes an endoscope down to the duodenum and exit of the common bile duct. It enables a plastic drainage tube to be placed in the bile duct in order to restore bile flow. During the ERCP, a puncture may be made in the duodenum or at the point where the bile duct opens into the duodenum in order to obtain tissue for examination under the microscope (cytodiagnostics).
Depending on the situation, the gastroenterologist may also perform an endosonography (internal ultrasound) by using a gastroscope (instrument for viewing the interior of the stomach) to insert a small ultrasound probe into the oesophagus, stomach and duodenum. This enables the probe to be placed directly on (or at least very near to) tumours in these organs or in their immediate vicinity (e.g. pancreas or lymph nodes) and thus allows pathological (illness-related) changes to be shown very precisely. In addition, a puncture needle can be passed down a working channel in the gastroscope and, using the ultrasound probe for visual guidance, is used to puncture neighbouring organs, tumours or lymph nodes in order to obtain tissue samples (cytodiagnostics).
More extensive tissue sampling (punch biopsies, for example) cannot be performed on the pancreas since it would cause too many complications. Before a final decision is made to operate on a tumour in the pancreas, a PET/CT scan – a combination of computerized tomography and scintigraphy – is also recommended since it can detect or rule out the presence of distant metastases. If distant metastases are present, it is not beneficial to operate.
If any doubts remain before treatment is planned, a diagnostic laparoscopy (visual examination of the abdominal cavity under anaesthetic) may sometimes need to be performed in order to rule out or detect any tumours in the peritoneum or liver. Moreover, blood analysis also needs to be done in order to determine enzyme levels (amylase, lipase) and tumour markers (CA 19-9 and CEA).
Tumour markers are various proteins in the blood that may be elevated depending on the type of tumour and can thus confirm the suspected diagnosis of a particular cancer. However, they are not reliable enough to be generally suitable for the early detection of tumours (screening).
I usually see patients with these diseases after they have been referred to me by a GP, gastroenterologist or oncologist. The investigations required have then generally been performed and the diagnosis or suspected diagnosis has been made. If you have a malignant tumour, the treatment plan is first discussed at one of the interdisciplinary Tumour Board Meetings (see above).
After discussing your case with colleagues from other disciplines at the meeting, I can then assess whether an operation is possible. I will then see you during my consultation hours and we will discuss the treatment plan together, in particular the operation planned, how long it will take, the necessity of the anaesthetic, the risk of complications and also therapy and care during your stay in the clinic. We will provide you with information about resuming a normal diet after the operation, mobility, wound care, how long you will stay in the clinic and the length of the convalescence period. We will also discuss the option of additional chemotherapy (treatment with medication) after the operation and what kind of long-term follow-up care you will receive.
Operation to treat tumours in the head of the pancreas
Operation to treat tumours in the tail of the pancreas
Operation to treat tumours that prove to be non-operable (palliative operation that aims to relieve symptoms)
Since these operations are (usually) major procedures that can only be performed under general anaesthetic, you will need to be admitted the day before the operation. No specific preparations are necessary. You will be given a light meal in the evening. The anaesthetist will discuss matters relating to the anaesthetic and post-operative pain treatment with you. I will also see you on the day that you are admitted and we will be able to discuss any final questions about the procedure. You must not eat or drink anything for at least six hours before the operation.
Operations on the pancreas must always be performed under general anaesthetic and through an incision in the abdomen (usually a transverse opening in the upper abdomen). The laparoscopic technique (minimally invasive abdominal endoscopy) is only used in a few selected cases (small benign tumours in the tail of the pancreas). In all tumour operations, the removal of the lymph nodes near the organ or tumour is an important part of the procedure.
At the start of the Whipple procedure, the surgeon needs to determine whether it can in fact be performed. If liver metastases (tumours that have spread to the liver) are present or if the tumour has grown extensively into the blood vessels, the patient will not benefit from the procedure since the disease is likely to return quickly. If only small vessel regions are affected, simultaneous vessel replacement can enable the operation to be performed. The Whipple procedure is one of the most major, demanding and complex operations in the abdominal region since the head of the pancreas is closely connected anatomically to the duodenum and common bile duct. Resection of the head of the pancreas (with the tumour) means the simultaneous removal of the duodenum and bile duct. It is vital here to safely preserve the flow of blood from the intestine to the liver (vena portae) and the arteries to the liver, stomach and intestine. After the head of the pancreas has been removed, three connections to the small intestine must be made to enable food to flow from the stomach, bile to flow from the common bile duct and secretions to flow from the remaining tail of the pancreas. These connections, especially the connection between the pancreas and the intestine, must be made particularly carefully in order to prevent complications. This demanding operation takes four to five hours.
In procedures to treat malignant tumours in the tail of the pancreas, the tail is removed along with the spleen since the two are closely connected (common blood supply). The difficulty with this procedure is that the tumours, which are frequently only detected at a late stage and so are relatively large, may have grown into the blood vessels (particularly the main artery of the liver). While it may be difficult to remove tumours from this blood vessel, the blood supply to the liver is vital and must on no account be affected. Problems may also be caused by the cut edge of the pancreas. It must be sutured closed well or connected to a loop of intestine in order to avoid post-operative complications.
If the procedure “only” involves the removal of a (suspected) benign and relatively small tumour in the tail of the pancreas, the tumour can be removed while preserving the rest of the pancreas and the spleen (enucleation). Ideally, an operation of this kind can even be performed laparoscopically (in a minimally invasive videoendoscopic technique; also known as keyhole surgery) in experienced hands.
Despite careful and state-of-the-art diagnostics, in at least 20% of cases a situation will be revealed during the procedure that will make removal of the tumour impossible (if the tumour has grown into neighbouring organs or vital blood vessels) or not a feasible option (if liver metastases are present, for example). A palliative situation then arises; in other words, the aim must then be to ensure that the patient enjoys as good a quality of life as possible for their remaining months. Since the tumour in the head of the pancreas can narrow the bile duct (jaundice) and/or block the duodenum (stomach emptying disorder), a bypass must be created in order to relieve the situation. To this end, a connection between the common bile duct and a loop of small intestine (hepaticojejunostomy) or between the stomach and small intestine (gastroenterostomy) is created. This enables normal food intake to be maintained and bile to be drained despite further tumour growth.
Pancreas head resection involves joining the cut edge of the pancreas (including its outlet duct) to the small intestine by sutures. If this join starts to leak (within the first five to seven days), pancreatic juice – with its digestive enzymes (see above) – can enter the abdominal cavity and cause serious problems such as infection or even bleeding. This rare complication (2 to 3%) is therefore greatly feared. The sutured connections to the bile duct and stomach are less critical, but may also cause complications in rare cases. Stomach emptying disorders are very typical and common initially, but always disappear after around two weeks. Removing pancreatic tissue can lead to a loss of function (around 20 to 30%). Insufficient enzymes mean poor digestion (recognizable by diarrhoea), but this can be easily compensated by enzyme tablets. A lack of insulin is rather more serious; this causes (as a result of the operation) diabetes, which may need to be treated with insulin injections. Otherwise, the usual range of complications after major surgery may occur, such as pneumonia, infection of the bladder or wound infection; the overall complication rate is around 15 to 20%.
The range of complications is smaller for pancreas tail resection, but here too leakage of digestive enzymes may occur at the cut edge. In the case of palliative bypass surgery, problems with the healing of joins with the bile duct or stomach are possible but fairly rare.
After pancreas head resection, you will spend at least one night – sometimes one to two days – in the intensive care unit. All the necessary painkillers will be administered. The nursing staff will help you to move around – at least into an armchair – straight away. For the first few days you will only be able to take liquids – a small amount initially, which will then be increased. Artificial feeding via an intravenous drip is necessary at this stage. Around four days after the operation you will be able to start transitioning to a normal diet, but this may be delayed slightly if stomach emptying disorder occurs. You will initially need to have blood taken every day to check your organ functions and diagnose any infection at an early stage. If all goes well, the intravenous drip can be removed after around five to seven days as can the drain in the abdominal cavity if there are no signs of leakage. For the other (more straightforward) pancreatic procedures, the recovery stage is generally shorter and less complex. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. Depending on the extent of the surgery and any possible complications, you will stay in the clinic for around 12 days for pancreas head resection; the length of stay will be shorter for laparoscopic removal of a small benign tumour.
Pancreas head resection is major surgery and we recommend that most patients – particularly those who live alone – go away to convalesce after they have been discharged from the clinic. You may feel very tired and weak at first. Light sporting activities can be resumed after around one month. You are likely to be unable to work for around two months, possibly longer if follow-up treatment is required. In the medium term, however, you will be able to enjoy a virtually normal quality of life. If you have had a more minor pancreatic procedure, the recovery time will be shorter.
As soon as the tissue sample for a malignant tumour has been examined under the microscope, the histopathological tumour stage can be determined. The situation is then discussed at our interdisciplinary Tumour Board Meeting and additional chemotherapy (treatment with medication) may be recommended in order to improve the prognosis. This is an outpatient procedure, usually lasts around three months and may be accompanied by (significant) side effects. Follow-up checks generally depend on the patient’s symptoms. Very frequent and time-consuming check-ups are not absolutely necessary since treatment options are limited if the disease returns.
In recent years optimized surgical techniques and modern chemotherapy have slightly improved the prognosis of pancreatic cancer, which was previously very poor. Nevertheless, this disease still has a very high recurrence rate (approx. 70% within three years). Unfortunately, there are not yet any methods available for the early detection of this malignant tumour.
The prognosis for the benign tumours mentioned above is generally good.
A wide range of diseases of the lungs and pleura (the membrane lining the chest cavity and covering the lungs) need to be treated by surgery. Procedures include the investigation of suspicious pulmonary nodules, the removal of benign and malignant tumours, and the treatment of diseases of the chest cavity such as accumulations of fluid, suppurations (formations of pus) or pneumothorax (see below). Although surgery in the chest cavity (thoracic surgery) is not one of my personal specialities, I can perform the most common procedures in this region at a high level thanks to many years of activity in this field.
If a suspicious nodule has been detected on chest X-ray, further investigations are necessary. The investigations start with computerized tomography and bronchoscopy (visual examination of the airways: windpipe, bronchial tubes). A bronchoscopy involves the pulmonologist (lung specialist) inserting a flexible endoscope through the mouth or nostril. This method allows tumours to be diagnosed and tissue to be taken from these tumours, lung segments that are blocked by secretions to be reopened by suctioning, and foreign objects to be removed. The investigation can be performed as an outpatient procedure without a general anaesthetic. If these diagnostic tests and any tissue sample taken do not lead to a clear diagnosis, an operation is necessary.
Primarily, tissue can be taken using a minimally invasive thoracoscopic technique. During a thoracoscopy (visual examination of the chest cavity), a video camera and rod-shaped surgical instruments are inserted into the chest cavity under anaesthetic through small incisions between two ribs. One lung is ventilated and the other (the lung to be operated on) collapses, giving the surgeon a good overview of the chest cavity. A thoracoscopy saves you from having to undergo a large incision, pain and unattractive scarring. Many but not all thoracic procedures can be performed in this way.
If a malignant tumour is detected, at least one entire lobe of the lung will usually need to be removed.
A large accumulation of fluid in the chest cavity, which occasionally occurs in advanced cancer (and is known as malignant pleural effusion), can cause severe breathing difficulties. Since punctures can only relieve the symptoms temporarily, thoracoscopic surgery with pleurodesis (obliteration of the pleural cavity) is indicated here. Occasionally, after pneumonia has been treated with antibiotics the patient’s fever continues and his or her condition does not improve. A possible cause is infection of the pleura accompanied by the formation of an accumulation of infected fluid in the chest cavity (known as pleural empyema). This is treated by thoracoscopic flushing out of the purulent fluid and chest drainage (fluid or air is drained off through a tube).
In the case of spontaneous pneumothorax, air escapes from the lung into the space between the chest wall and the lung (pleural cavity). The majority of events of this kind occur suddenly and are caused by the rupture of an air-filled blister (bulla and bleb) on the surface of the lung (which is usually a congenital abnormality or has developed in association with emphysema). Primarily, a chest tube will then usually need to be inserted to drain off the air and is often sufficient. This is a plastic tube inserted between the ribs into the pleural space and connected to a suction system (vacuum). If, however, air continues to build up in the pleural cavity and cannot escape (one-way valve effect), the lung (on the affected side) and even the heart may become dangerously compressed. This is known as tension pneumothorax.
In extreme cases, the lung and cardiopulmonary functions are restricted in a life-threatening manner. To relieve the situation, an emergency drain (see above) must be inserted into the chest cavity through the chest wall. Symptoms may also be far less severe, however, and hardly noticed by the patient. If a chest drain proves to be insufficient or the pneumothorax occurs repeatedly, thoracoscopic pleurodesis is advisable. A pneumothorax may also occur as a result of injuries in the chest region (fractured rib, stab wound, bullet impact) or as an early complication after a lung operation.
Symptoms of malignant lung tumours can include a persistent cough, occasionally associated with pneumonia and sometimes the coughing up of blood. Smokers have a significantly higher risk. A large proportion of lung tumours (both benign and malignant) are detected as “incidental findings” in patients who do not have any symptoms when a chest X-ray is performed for another reason.
Fluid accumulation in the chest cavity (pleural effusion) only causes symptoms once it has reached a certain volume (at least 1 litre). Patients initially notice that they are short of breath after activity or exercise; this may subsequently occur even when they are at rest. Doctors should be on immediate alert if a patient who is known to have a malignant tumour is experiencing symptoms of this kind and should order the necessary investigations. Symptoms of a spontaneous pneumothorax (see above) generally include pain on the affected side that develops suddenly and is usually made worse by breathing. In addition, patients may experience shortness of breath of differing severity.
A normal or “conventional” X-ray of the thorax (chest including the lungs) is frequently the first step in the diagnosis of diseases of the lungs or chest area. In many cases, it enables a meaningful diagnosis or suspected diagnosis to be made. When lung and chest diseases are investigated more closely, the main focus is on a computerized tomography (CT) scan of the thorax. This technique gives a very detailed picture of the various diseases and often allows a precise diagnosis to be made.
The next useful investigation for even better differentiation and for obtaining cell material for microscopic analysis is a bronchoscopy (visual examination of the airways). It enables the airways to be assessed and, if necessary, tumours to be visualized – if they can be accessed in this way – and a biopsy of the tumour to be performed (removal of tissue). If the tumour cannot be reached by a bronchoscope, a biopsy can also be performed via a puncture through the skin and the chest wall into the lung using a CT scan as a visual aid. If a patient has a malignant lung tumour, a PET/CT scan is usually also arranged in order to plan treatment. This combination of computerized tomography and scintigraphy enables a very reliable diagnosis to be made as to whether the tumour is malignant and whether distant metastases (tumours that have spread) are present.
Finally, a lung function test must always be performed before surgery on the lungs. It provides information about the function of the lungs and the necessary reserve if it is planned to remove part of the lungs by surgery. A blood test is also performed before an operation in order to rule out anaemia, diagnose any infection that may be present and check blood clotting and the other organ functions.
I usually see patients with these diseases after they have been referred to me by a GP, pulmonologist (lung specialist) or oncologist. The investigations required have then generally been performed and the diagnosis or suspected diagnosis has been made. If the patient has a malignant tumour, his or her situation is first presented at an interdisciplinary Tumour Board Meeting. Cases of this kind are discussed at these weekly meetings, which are held in competence centres for tumour treatment in the presence of all necessary specialists. The next treatment steps are subsequently proposed. A surgeon, oncologist, radiotherapist, gastroenterologist, pulmonologist, pathologist and possibly other specialists are present. After discussing your case with colleagues from other disciplines at the meeting, I can assess whether an operation is necessary and possible and whether pretreatment (with chemotherapy, i.e. with medicine, and/or radiotherapy, i.e. with radiation) may be needed as a first step. I will then see you during my consultation hours and we will discuss the treatment plan, in particular the operation planned, how long it will take, the necessity of the anaesthetic, the risk of complications and also therapy and care during your stay in the clinic. We will provide you with information about the situation after the operation (thoracic drainage, possibly treatment with antibiotics), mobility, wound care, how long you will stay in the clinic and the length of the convalescence period. If you have a malignant tumour, we will also discuss the possibility of additional chemotherapy after the operation and what kind of long-term follow-up care you will receive.
Operation for suspicious, benign and malignant tumours
Operation for malignant pleural effusion
Operation for pleural empyema
Operation for pneumothorax
Since the majority of these operations are major procedures that can only be performed under general anaesthetic, you will need to be admitted the day before the operation. No specific preparations are necessary. You will be given a light meal in the evening. The anaesthetist will discuss matters relating to the anaesthetic and post-operative pain treatment with you. I will also see you on the day that you are admitted and we will be able to discuss any final questions about the procedure. You must not eat or drink anything for at least six hours before the operation.
Apart from the straightforward insertion of a chest drain (tube to drain off fluid or air) in the chest cavity, which can be performed under local anaesthetic, all thoracic procedures require a general anaesthetic. This involves placing a tube in the airway for ventilation which enables only one lung to be ventilated. No air is blown into the lung to be operated on, causing it to collapse. This creates the space needed to perform surgery, specifically thoracoscopic procedures. The patient is always placed on his or her side with the lung to be operated on at the top.
Thoracoscopy involves inserting a video camera and rod-shaped surgical instruments through the chest wall via at least three small incisions (each measuring between 5 and 12 mm). One-lung ventilation causes the lung on the side to be operated on to collapse and the surgeon has a good overview of the chest cavity. As soon as the tumour has been identified, the relevant part of the lung is severed using a stapler with a minimum safety margin of around 1 cm from the tumour. These scissor-like devices can grab the lung tissue in steps of a maximum of 6 cm, cut through and seal the cut surface (including the blood vessels and airways) on both sides using a large number of small titanium staples. The severed tissue is then put into a plastic bag and retrieved through one of the existing small incisions and passed to the pathologist for intraoperative frozen section analysis.
The pathologist examines the tissue under the microscope during the operation. The pieces of tissue removed during the procedure are frozen, cut into very thin slices and examined under the microscope. The pathologist can then accurately determine within 15 to 20 minutes whether the tumour is malignant or benign, which may be of key importance for the further course of the operation.
If the tumour is benign, chest drains (see above) are placed and the operation is then ended. If the tumour is malignant, further lung resection is required (lung tissue is severed and removed). If conditions allow, this can be done thoracoscopically; in difficult situations, however, open surgery must be performed on the lung.
The principle of tumour surgery on the lung (open or thoracoscopic) is to remove the affected part of the lung (segment, lobe or entire lung on one side) in an anatomically correct manner in order to completely remove the tumour. To this end, the air tube (bronchus) belonging to this part and the corresponding artery and vein must be exposed and divided. In addition, the surrounding lymph nodes must be removed. Finally, chest drains (see above) are placed; the chest is then closed. If it has been ascertained before the procedure that the patient has a large malignant tumour which has grown, for example, into the large blood vessels near the heart or into the chest wall, surgery is primarily performed on the open chest cavity.
After the instruments required for the thoracoscopy (visual examination of the chest cavity, see above) have been inserted, the effusion is first suctioned off. A tissue sample is then taken from at least one site in the pleura affected by a tumour for further investigation. As large an area as possible of the pleura on the thoracic wall is then roughened using a swab (or something similar). The pleural space is then sprayed with sterile medical talcum powder, which is distributed throughout the chest cavity. After chest drains have been placed (see above), trocars and instruments have been removed and the small incisions have been closed, the operation is ended. This procedure causes the pleura of the lungs and the pleura of the chest wall to adhere and grow together. This should prevent any new effusion from forming or, if reaccumulation of the effusion does occur, greatly restricts its extent.
After the instruments required for the thoracoscopy (visual examination of the chest cavity; see above) have been inserted, the pus is first suctioned from the chest cavity. All adhesions between the pleura of the lungs and the pleura of the chest wall are then released in order to open up any encapsulated and pus-filled abscess cavities that may be present. Finally, the empyema/abscess membranes are removed from the pleura of the lungs, in particular. After chest drains have been placed (see above), trocars and instruments have been removed and the small incisions have been closed, the operation is ended.
After the instruments required for the thoracoscopy (visual examination of the chest cavity; see above) have been inserted, the lung is first examined for the presence of air-filled blisters (bullae and blebs). These cause pneumothorax and are found at the apex (top) of the lung. The apex is therefore resected (removed) using a stapler, with only a very small part of the lung being lost. As large an area as possible of the pleura on the thoracic wall is then roughened using a swab (or something similar). After chest drains have been placed (see above), trocars and instruments have been removed and the small incisions have been closed, the operation is ended. As a result of this procedure, the cause of the disease is eliminated and the pleura of the lungs adheres to the pleura of the chest wall, making recurrence of the pneumothorax virtually impossible.
An air leak is a quite common complication following surgery on the lungs, with air leaking from a suture line in the lung or airways into the chest cavity. This becomes apparent when air is seen to exit the chest through the drain tubes (see above). For as long as this is the case, the chest drains cannot be removed since a pneumothorax (see above) would otherwise result. In most cases the problem resolves itself and the air leak heals within a few days. If not, a reoperation to close the leak may occasionally be required.
The mobility of the thorax may be limited as a result of pain, which can cause individual sections of the lung to be underventilated (atelectasis) and lead to pneumonia. Antibiotics, good pain management and physiotherapy can solve this problem. If the lungs are already severely damaged (e.g. pulmonary emphysema), however, the patient may experience shortness of breath and need oxygen. Complications such as post-operative bleeding, wound infections, thrombosis and pulmonary embolisms are no longer common due to improved techniques and preventative measures.
After open thoracic surgery, you will be monitored in the intensive care unit for at least one night. A fine catheter will be inserted near your spinal cord as part of the anaesthetic process to provide pain relief and will allow you to “switch off” pain during the first few days. After minimally invasive (thoracoscopic) procedures, you will not need to stay in the intensive care unit and treatment with conventional painkillers is sufficient. In all cases, your mobility will be significantly restricted by the chest drains (see above) attached to a vacuum source. Nursing staff will be able to help you into an armchair, however. The chest drains can usually be removed on about the fourth day after the procedure and you will then be able to move around normally (i.e. you will also be able to leave the room). You will be able to eat and drink normally straight after the procedure. Depending on the disease and the extent of the operation, oxygen will be administered through a catheter in your nose for the first few days. Wound care after these procedures is usually straightforward. As after any operation, an antithrombotic drug will be injected into your leg every day while you are in the clinic in order to prevent thrombosis and pulmonary embolisms. You will stay in the clinic for around eight days after open thoracic surgery and for around five days after a minimally invasive operation.
After open thoracic surgery, you should consider going away to convalesce after you have been discharged from the clinic – particularly if you still have limited lung function (and if you live on your own). Depending on the underlying disease and extent of the operation, you may feel very tired and weak at first. After one to two months you will usually have achieved a virtually normal quality of life and will be able to resume light sporting activities. You may then also be able to return to work, depending on how much of your lungs has been removed, any follow-up treatment planned and the type of work. In severe cases, your physical fitness may be permanently and significantly impaired.
After minimally invasive thoracoscopic procedures, the recovery period can – depending on the underlying disease – be very short and you may be able to return to work after about a week (in the case of pneumothorax, for example). This obviously does not apply if you have had surgery to treat malignant pleural effusion. Patients with this diagnosis receive palliative care; in other words, the primary goal is to relieve their symptoms, and their quality of life varies greatly.
As soon as the specimen (tissue sample) of the malignant tumour has been examined under the microscope, the histopathological tumour stage can be determined. The situation is then discussed at an interdisciplinary Tumour Board Meeting and radiotherapy (radiation) or chemotherapy (medication) may additionally be recommended in order to improve the prognosis. Both types of treatment are outpatient procedures; radiotherapy usually takes around four weeks, while chemotherapy lasts about three months, and both treatment forms may be accompanied by (significant) side effects. Follow-up checks are usually performed by a pulmonologist (lung specialist) and depend on the tumour stage at the start of treatment, the age of the patient and current international guidelines.
The prognosis of malignant lung tumours is only favourable for early stages. Unfortunately, around 80 per cent of all patients diagnosed with lung cancer die within five years. This can only be improved if patients at risk (smokers) undergo lung screening, i.e. a preventative computerized tomography (CT) scan. Since patients with malignant lung tumours (“smokers’ cancer”) only have a chance of recovery if the disease is diagnosed at an early stage, screening is worthwhile for people at risk. Those at risk are female and male smokers and ex-smokers aged between 55 and 74 who have smoked at least one packet of cigarettes per day for 30 years or at least 30 cigarettes per day for 20 years. People in this risk group should visit their doctor or our practice so that a CT scan of their lungs can be arranged.
The prognosis for patients who have undergone surgery for malignant pleural effusion is equally poor; since the disease cannot be cured, this is a palliative procedure. The situation for patients with benign lung tumours, pleuraempyema or pneumothorax is quite different; these patients are usually cured after their operation.